Town of Winthrop : Record of Deaths 1910-1912, Part 24

Author: Winthrop (Mass.)
Publication date: 1910
Publisher:
Number of Pages: 956


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 24


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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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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