USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 19
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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, peritoneum, 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: Mcasles (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.
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
BOSTON
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME alice C. Foster
[If married or divorced woman or widow give maiden name, also name of husband.] alice C. Auvotre villa, (husband; George 8. Fosta) @RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE when
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
mamed
6 DATE OF BIRTH
?
1
(Month)
(Day)
1862 (Year)
7 AGE
48
yrs.
mos. 3
ds.
or .... . min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Housewife
(b) General nature of industry, business, or establishment in which employed (or employer)
House work
9 BIRTHPLACE
(State or country)
Balón
10 NAME OF
FATHER
John Pusistevilla
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
St. John New Foundland
12 MAIDEN NAME OF MOTHER many
2
13 BIRTHPLACE
OF MOTHER
(State or country)
new Found land
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
George 8, 4 oster
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
november
28, 190
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from 1908 , 191 to 1910 , 191. -
If LESS than
I day, ...
hrs.
that I last saw her alive on.
, 1910
and that death occurred, on the date stated above, at.
2.30Pm.
The CAUSE OF DEATH* was as follows :
Heart Disease (Mutual Requisiti)
at least 3 years
(Duration)
yrs. .
mos.
...
ds.
Diabetes
Contributory ..
(SECONDARY)
at least 6 minutter
(Duration)
yis.
mos.
ds.
(Signed)
pr 29, 90 (Address).
35 6 mail bow for
* 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.
ds.
State
yrs.
In the
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 Nov. 50, 10 491
(Address)
15 Trident av peintures Calvary Cometer:,
20 UNDERTAKER
Holm. Varen Yfm
ADDRESS
54. a Sheet,
1 PLACE OF DEATH
mutton mars (No. 15 Inclear Que Sti Ward)
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
Filed 191
M.D.
1
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 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 kungs, metetges, Veritonaeum, 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop
(No. 10, Foodwe are St. ,. Ward)
2 FULL NAME
alive C. Fenster
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
15 Trident ave
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month) (Day)
1
(Year)
7 AGE
If LESS than [ day, ........ hrs.
St 55 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)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address)
Filed .. 191 ..
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
non
28, 190
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
natural causes: heart disease -
(Duration) ...
yrs.
mos.
ds.
Contributory (SECONDARY)
.. (Duration)
mos. ds.
(Signed)
Senza Buyers Margrethe yrs. ..
M.D.
hm29, 1910 (Address) MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
ds.
State
.. yrs.
In the
.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
191
20 UNDERTAKER
ADDRESS
shootd be stated EXACTLY. PHYSICIANS should state rly classified. "Exact statement of OCCUPATION is very
CAUSE OF DEATH in plain terms, so that it may wu (
N. B. - Every item of information should be carefully sup. important. See instructions on back of certificate.
11 BIRTHPLACE OF FATHER (State or country)
2882 winthrop (City or toun.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
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 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 discase; 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. For VIOLENT DEATHS 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 - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of " Contributory."
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
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
Warten of Has No ... 4 athenian Circle Visor 28 RAppo
2 FULL NAME Baby Harus
[If married or divoreed woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chica
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Male
+ COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH
November 28 (Month)
(Day)
1910
.,
(Year)
7 AGE
If LESS than I day, J. hrs.
X yrs. mos.
ds.
or K min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer)
' BIRTHPLACE
(State or country)
Wanthet Mins
10 NAME OF
FATHER
Echarles. L. Hansen
PARENTS
11 BIRTHPLACE OF FATHER
(State or country) Hannover U. H.
12 MAIDEN NAME OF MOTHER Clara. L. Haynes
13 BIRTHPLACE
OF MOTHER
(State or country)
Boston
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
15
Filed . 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
200
(Month)
(Day)
28, 19:0
(Year)
17
I HEREBY CERTIFY that I attended deceased from
1
nov 28
... . 1910
., to
, 1910,
that I last saw h.
LAMlalive on
nev 28
, 191 0,
and that death occurred, on the date stated above, at/030 0Pm.
The CAUSE OF DEATH* was as follows :
marasmus 5 horasion).
Contributory. (SECONDARY)
.. (Duration) .
yrs. .
mos.
....
ds.
(Signed)
191 .... (Address)
Elintop
* 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
, 1910
20 UNDERTAKER
ADDRESS
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
I 1
yrs. .
mos. ..
ds.
., M.D.
now ..
ʼ
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, Łoco- 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 -4 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 10 occupation whatever, write None.
.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broneho- 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 statei unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Nevci 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," " Marasmu"," " 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 septicemia," " 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.
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF )A DEATH
(CITY OR TOWNS
FULL NAME
Registered No.
Date of
Death S
Age 14
.. years.
8
months. /2 .days
STATISTICAL DETAILS
SEX
COLOR Mente
SINGLE, MARRIED, WIDOWED, OR DIVORCED
.
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
NAME OF FATHER Forum Cafen 19cago Cm
BIRTHPLACE OF FATHER$
MAIDEN NAME OF MOTHER Della. H. 1 agem
BIRTHPLACE OF MOTHER $
OCCUPATION School 30m
INFORMANT §
John .C. 19 egy5 Cm
PHYSICIAN'S CERTIFICATE
to 19 I HEREBY CERTIFY that I attended deceased during last illness, from 19
..... , that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary :
.(DURATION) ... DAYS
Contributory :
.. (DURATION) ... DAYS
(Signed)
M.D.
19 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Place of Death ? . years ..
. months. days
Where was disease contracted, If not at place of death ?
Filed
19
Clerk
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
19 / 0
UNDERTAKER
ADDRESS
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If in a Hospital or Institution, give its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
# State or country ; also city, town or county, If known,
§ Name and address of person giving statistical details, Il Name of cemetery.
1
ALL NAMES TO BE IN FULL
.......
Place of l
Death *
S
1970
Residence
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS SHU:AG 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
Metcalf Hospital
St. Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
19422
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month) (Day)
(Year)
7 AGE
If LESS than I day ......... hrs.
or .min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE (State or country)
10 NAME OF FATHER
PARENTS
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
IS Filed , 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
un
29 (Dấy)
, 1960 (Year)
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : Fracture of the skull with
associated harmontage, con- fusion, and oedema of brain, caused by jungeing d ds.
Contributory. a conflagration (SECONDARY) (Duration) yrs.
mos. ds.
(Signed)
Serge Burgers Dagrally.
M.D.
191℃ (Address).
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death,
.. yrs.
mos.
ds.
State
.. yrs.
.mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence .
DATE OF BURIAL
19 PLACE OF BURIAL OR REMOVAL Winthrop, mass
....
191
20 UNDERTAKER
le. R. Bennison
ADDRESS
Winthrop Mess
2881 Winthrop (City or town.)
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Springfield
.C. Begge, Jr.
16 DATE OF DEATH
(Month)
14 yrs. mos. ds.
11 BIRTHPLACE OF FATHER (State or country)
Nov. 29, 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) Salcs- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The Tutorial 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.
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