USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 21
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REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec
1
(Month)
(Day)
4
, 1910
(Year)
17
I HEREBY CERTIFY that I attended deceased from
1910
, to.
Dec 14
.. , 1910
If LESS than
1 day,
hrs.
that I last saw her
alive on
De 14
, 1916,
and that death occurred, on the date stated above, at/ 0
p.m.
The CAUSE OF DEATH* was as follows :
Strangulated lerma.
operativi
. (Duration)
.yrs.
mos.
8
ds.
Contributory
(SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
31 Mutcall
M.D.
191.Q .. (Address)
174 Woning st
* 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.
3
ds.
State
In the
yrs.
mos. .
ds ..
Where was disease contracted,
If not at place of death ?
39 NevadaSt walkup
usual residence ..
Former or
39
Nevada St.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
C
20 UNDERTAKER
ADDRESS
...
yrs.
8
mos.
2
ds.
des. 14 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 enginecr, 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-
1110
2
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: 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Metcal Hospital (No. 174 Muchom St. St. :..
174) Theloop St
2 FULL NAME
lebaume lehandluy
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
(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
male
4 COLOR OR RACE
Write
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
December (Month)
15
(Day)
, 19.10
(Year)
7 AGE
If LESS than
I day, 20 hrs.
·mas.
ds.
or 25 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) ·
Muchasto maso
10 NAME OF
FATHER
Powell B. lehandley
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Oladiin no. Carolina
12 MAIDEN NAME OF MOTHER
Fanny Pearl Hauff
13 BIRTHPLACE OF MOTHER (State or country) Greenville Tenn
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
OF. A. Okryss
(Address)
174 Of manttauf St.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
alec.
(Month)
15 (Day) ., 19!0 (Year)
17 I HEREBY CERTIFY that | attended deceased from Des. 15. (1.35a.m) 191 a, to Dec. 15 (10.20,20), 1910. that I last saw him alive 9,56P. m. 1910 and that death occurred, on the date stated above, at. ( & P. m. The CAUSE OF DEATH* was as follows :
Premature. no Vitality
.(Duration)
yrs.
mos.
ds.
Contributory ...
(SECONDARY)
(Duration)
yrs.
mos. .
ds.
(Signed)
1
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
DATE OF BURIAL
20 UNDERTAKER
ADDRESS
V
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
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
Ward)
Filed 191
191
(Address)
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits cau 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, 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 state 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," "Hemorrhage," " 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.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) (‹
12 MAIDEN NAME OF MOTHER 4
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Franck Boney
(Address)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec.
(Month)
22
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
1910, to
Dec. 22ª, 1910
that I last saw her alive on ...
Dea. 22ª , 1910.
and that death occurred, on the date stated above, at 10/,m.
The CAUSE OF DEATH* was as follows :
Cystic Cancer
Uncertain.
.(Duration)
1
yrs. .
mos. ..
ds.
Contributory
Exhaustion
(SECONDARY)
.(Duration)
yrs.
(Signed)
tue, 2+4.1916
(Address)
Winthrop
.,
M.D.
* If deatb 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.
mos.
ds.
Where was disease contracted,
if not at place of death ?..
Former or usual residence ....
19 PLACE OF BURIAL OR REMOYA
DATE OF BURIAL
die 24
, 191 Ły
20 UNDERTAKER
ADDRESS
Filed 191
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH meccail Hospital
(No.
St. ;.
Ward)
(City or town.) Ako [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Frances ..
Joney
Francer. Bowey
{If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 303 Shirley St wieder 2204
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
-
4 COLOR OR RACE
Colore
female
6 DATE OF BIRTH Akar
2
(Month)
(Day)
, 1880
(Year)
7 AGE
If LESS than
I day .... . hrs.
41
yrs.
mos.
21
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
mos.
RS ds.
In the
., 1910.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
undlow
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
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. Bnt in many cases, especially in industrial employments, it is uecessary 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 tho 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, uot 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, writo 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 saure disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Cronp") ; Typhoid fever (uever 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 state? 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," " 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 septicaemia," " PUERPERAL peritonitis," etc. State canse for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under tho 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 Criminul 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.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
Winthrop
RETURN OF A DEATH
(CITY OR POWN.)
FULL NAME
Catherine Arm Manner
Registered No ..
Place of )
Death
S
Metcalf Hospital
Death
.months.
3
.days _
STATISTICAL DETAILS
SEXY
Jemale
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME t
HUSBAND'S NAME t
BIRTHPLACE +
NAME OF FATHER James & Farmer
BIRTHPLACE OF FATHER$ Sherman Me.
MAIDEN NAME OF MOTHER Clara Finnegan megan
BIRTHPLACE OF MOTHER $ Staceyville me.
OCCUPATION
INFORMANT § annes Farmer 253 main St Winthrop
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Du 20" 19/0 to ice 22" 19/0, 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 :
Premature
Wade 1 Julally U wildly.
(DURATION).
3
DAYS
Contributory :
(Signed)
318hul cal
(DURATION). ........ . DAY8
M.D.
// (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Piaco of Death ?
years.
months.
3
days
Where was disease contracted,
met calf itoJelent
If not at place of death ?.
Filed
19
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, glvo 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. || Name of cemetery.
PLACE OF BURIAL OR REMOVAL I
Holy lower
DATE OF BURIAL
DEC 23 1910
UNDERTAKER John F Malay
ADDRESS
79 atlantic
Date of l
Dec 23
19/ 0
Residence
283 Matin St Westlich
.years.
Dec. 23, 1910
..
[1-'09-2MI.]
Medical Examiner's No. 2303
Permit No.
19330
RETURN OF A DEATH. BOSTON, MASS.
1909 2 1
Date of Death,
Dec. 25- 1910
Name in full, Charles Blanchard
(If married or divorced woman give maiden name, also name of husband.)
Sex, Tele
Color, White
Condition,
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.)
Age, 30 Years, Months, Days. Occupation, Seaman
Residence, E Boston
Ward
Place of Death, Boston Harbor
(State year, month and day.)
Place of Birth, Unknown
Date of Birth, Union un
Unknown
Name and Birthplace of Father, Maiden Name and 1111 Birthplace of Mother, Place of Interment, Mt. Hope
Lewis Jones , Son. Undertaker.
Certificate of the Medical Examiner.
I hereby certify that
age 30 , residence,
Charles Blanchard
East Boston
-
who died on the 25 th day of December , 1910,
-
came to hi death from
Cause : wning
Manner : accidental (member crew Sch. Dans Palmer, wrecked in Broad Sound) Larry Burgers tagrally 1 Medical Examiner for Suffolk County.
Body recovered on Short Beach, Winthrop, adit. 1910
Reid mar. 14.
4 REC.
Charles Blanchard De 25, 1910
Charles Blanchard
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. CI Artonvia C .. St. ; Ward)
Huch Treanor
'FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 1 Atlantic St. Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Jule
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED inCle
(Write the word)"
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
1 day, . ..
. hrs.
72
yrs.
mos.
ds.
Or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
cson
(b) General nature of industry,
business, or establishment in
which employed ( or employer).
9 BIRTHPLACE
(State or country)
Ireland
10 NAME OF
FATHER
Bernard
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Tary VeAlLister
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Fre. Daniel Chalk
(Address)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec
29
1910
(Month) 024 (Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
auque
. 191.0 , to
Dec 29,1910,
that I last saw ha
alive on
Sec 2 4 , 1910,
and that death occurred, on the date stated above, at / c.m.
The CAUSE OF DEATH* was as follows :
Branchitão
(Duration) .yrs.
mos.
ds.
Bronchitis 2 Wk.
Contributory
(SECONDARY)
mos. ..
ds.
Debility
(Duration)
Dellain Fr. 13 coresa.
yrs. 6.
M.D.
(Signed)
vec 30
1910 (Address).
3 Fere fr
* 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 . COLVELO
DATE OF BURIAL
), 1910.
20 UNDERTAKER
ADDRESS
Filed .. 191
...
BOSTON (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Dec. 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) 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 (tho 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.
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