USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 24
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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 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," " 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 septicacmia," " 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
12 MAIDEN NAME OF MOTHER Matilla- Riel
1ª BIRTHPLACE OF MOTHER (State or country) Rouses Point 11. 4,
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH Jan 30 (Month) (Day)
1917 (Year)
,1911 17 I HEREBY CERTIFY that attended deceased from (Year) 26, 1911, to 0 , 1917 . 1 , 191) , and that death occurred, on the date stated above, at. 2.30 am The CAUSE OF DEATH* was as follows : Prematiny with
7 mos- wald Vitality
(Duration)
yrs. .
mos.
.4
ds.
Contributory. (SECONDARY)
(Duration) 31 Malcol
yrs.
mos. ds.
(Signed)
M.D.
Am30, 1911
(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
Carlingcon Carnela canada.
DATE OF BURIAL
21, 1911
ADDRESS
20 UNDERTAKER
GRB.
St. ;.. ....
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Função
Bryant
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
voluto
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Senja
6 DATE OF BIRTH
Jan (Month)
26
(Day)
7 AGE
yrs.
mos. 4 ds.
or X min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
2
9 BIRTHPLACE
(State or country)
10 NAME OF FATHER Herbert. H. Bryant
11 BIRTHPLACE OF FATHER (State or country)
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Waturt Muss No. 1 Claudia DL
(City or town.)
Registered No.
If LESS than I day, .hrs. that I last saw h 42 alive on
Jan . 30 , 1911
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of ocenpa- tion is very important, so that the relative healthfulness of varions 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 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, Hlousework, 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 cercbro-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 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," " 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 canse 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 Commmuwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winterin Mano .... (No. 18. Pea Jour Com
St. ;.
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
FULL NAME.
Sarah Maria HIÇ Lean
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
18 few town er
2 -
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
White
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
20
- yts.
x
mos.
x
ds.
or .. min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
at houn
1
(b) General nature of industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE (State or country) Sackville N.B.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Unknown
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)
18 Pen Jour Dan
15
Filed. 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
2
(Month)
2, 191
(Day)
(Year)
If LESS than Ja 721- 2, 191
1 day,
hrs.
that I last saw heA. alive on
4P
7 2+ 2
, 191 {.
and that death occurred, on the date stated above, at
... m.
The CAUSE OF DEATH* was as follows :
(Duration)
yrs.
mos.
2
ds.
Contributory (SECONDARY) Curtis
(Duration)
yrs.
Dos.
.ds.
(Signed)
, 191\ (Address)
263 W
* 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.
12 PLACE OF BURIAL OR REMOVAL
Cambridge Cemetery
DATE OF BURIAL
. 1911
...
20 UNDERTAKER
ADDRESS
Warchest
=
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Sara Maria Bower Widowof Robertm. M: Lean
Registered No.
17 I HEREBY CERTIFY that I attended deceased from
10 NAME OF
FATHER
John. & Bowes.
Mielly M.D.
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 Ilouse- keepers who receive a definite salary), may be entered as Ilousewife, Housework, or At home, and children, not gaiu- 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 disease; Chronic interstitial nephritis, etc. The coutributory (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 septicacmia," " 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 strect, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
1071 70
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 218 Lincalia
St. ;
Ward)
(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
4 COLOR OR RACE
White
.
11 6
(Month)
(Day)
1855
.,
(Year)
If LESS than I day, .. . hrs.
53 yrs. yrs. 2 mos. 26 ds.
Or ....... min. ?
Shy
9 BIRTHPLACE
(State or country)
Chelsea mars.
0
Langeauf.
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
| HEREBY CERTIFY that I attended deceased from
191@ ., to Jiet 22 , 191} , that I last saw hum. alive on Je cb 2c , 1911. and that death occurred, on the date stated above, at. m. The CAUSE OF DEATH* was as follows : Primary cause was Duodenal ulcer followed by peritonitis with perforation
.(Duration)
yrs.
5 mo
mos. ..
ds.
Contributory Perconto
(SECONDARY)
(Duration)
yrs. .
mos.
5
ds.
(Signed)
Horace & Soul
., M.D.
191
(Adress)
* 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
In the
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
2- 7, 191,1
20 UNDERTAKER
ADDRESS
2
(Month)
(Day) 2.
., 19!/. (Year)
3 SEX Male. 6 DATE OF BIRTH 7 AGE 8 OCCUPATION (a) Trade, profession, or particular kind of work 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (State or country) 12 MAIDEN NAME OF MOTHER PARENTS WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD. (b) General nature of industry, business, or establishment in which employed (or employer)
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
frace It May.
2 FULL NAME ttorace
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
-
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., C'arcinoma, 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 " ("( ongenital," "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 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Alexander Lewis Stubbs
Registered No.
Place of Death
#34 Willow Ave. Winthrop Mass
Date of Death.
Heb 4' 1911.
Age
76
.. years
5
.months
9
days
STATISTICAL DETAILS
SEX SEX Mile
COLOR A hile
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Vidower
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Buckshow Ne.
NAME OF FATHER
Reuben
BIRTHPLACE OF FATHER# Bucker out He
MAIDEN NAME OF MOTHER Melinda Levis
BIRTHPLACE OF MOTHER#
OCCUPATION
INFORMANT §
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Jan, 15. 1991 .... to that to the best of my knowledge and belief death occurred on the
Jeb. 4.19 !! date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
arterial eleroses with das
generation of the heart,
(DURATION) Irskwoman ..... DAY8
Contributory :
Edema of the lingo
(DURATION) 15 DAYS
(Signed)
M.D.
Yet 5.
1901 ..... (Address)
24 While-of-
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?
Days
Where was disease contracted, If not at place of death ?.
Filed
190
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, 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 detalls. Il Name of cemetery.
ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVAL II Hinitrof Cemetery
Wintherle
UNDERTAKER
E.G. Drown Kon
ADDRESS
DATE OF BURIAL
198/
Tel. ++, 1911
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
Wendlerot mar.
(No. 15 Egleton Park
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
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Febmay
5
1
(Month )
(Day)
191
(Year)
6 DATE OF BIRTH
1200
20
(Month)
(Day)
1800
(Year)
7 AGE
70 yrs. 2- mos ..
15 ds.
or ....... min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
Reluce
(b) General nature of industry,
business, or establishment in
which employed (or employer).
Z
Z
9 BIRTHPLACE
(State or country)
Saco. ME
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Hallin me
12 MAIDEN NAME
OF MOTHER
Elizabete Harm aford
13 BIRTHPLACE
OF MOTHER
(State or country)
Portland une
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
159 Wurdeturhan 8h
16 Filed. .... 191
REGISTRAR
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 REMOVAL Sacome
DATE OF BURIAL
2/8
..
191.
ADDRESS
20 UNDERTAKER
CRBu
191
(Address).
yrs.
.. .
mos.
1
ds.
Contributory
(SECONDARY)
mos. .
ds.
(Signed)
>
{Duration) 31 Metcalf Q .... yrs.
M.D.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
17
HEREBY CERTIFY that I attended deceased from
Feb 4'
1911
Feb 5
197
If LESS than I day, ..... hrs. that I last saw him alive on
to
Feb 52
1911.
and that death occurred, on the date stated above, at ..
1 pm.
The CAUSE OF DEATH* was as follows :
Selensis & Coronary arteries
(Duration)
(City or town.)
FULL NAME
Henry, Ormand. Higher
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
15 Egleton Park whichof Man
Registered No.
10 NAME OF
FATHER
Elisha. Hight
In the
Feb. 5 \\\\ ,
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. Tho question applies to each and every person, irrespective of age. For many occupations a single word or terin 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 Nonc.
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