USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 26
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mos.
ds.
Filed .. 191.
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
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- kecpers 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 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.
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 Printhrop Mars (No. 49 Lauramo in f. Russell.
Cottage avast ...
2FULL NAMEDauraman Ky. [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 49 Cottage Einz -
(City or town.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
11
19
(Day)
, 1820
(Year)
7 AGE
If LESS than
1 day, .. . . hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Builder.
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Marlboro Mass.
10 NAME OF
FATHER
Otis Russell.
PARENTS
11 BIRTHPLACE OF FATHER (State or country} Marlboro.
12 MAIDEN NAME
OF MOTHER
Jovana Pic
1ª BIRTHPLACE OF MOTHER (State or country)
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
feb. 14
(Monthı)
(Day)
( Year)
17 I HEREBY CERTIFY that I attended deceased from
191
, to.
191
-
that | last saw h ......
alive on ..
, 191 1
and that death occurred, on the date stated above, at ..
m.
The CAUSE OF DEATH* was as follows :
Pneumonia nova
(Duration)
yrs. .
. mos. .
7
ds.
Contributory.
. (Duration)
yrs.
mos. ds.
(Signed) .
Albul B. Dorman
M.D.
Feb 16, 191 . (Address)
Printhoop Mars
* 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 Marlboro
DATE OF BURIAL
2-17-1911
20 UNDERTAKER
It. C. Skaggs'
ADDRESS
Herthaof.
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
., 19 !!
(Month)
90 yrs.
2 mos.
26 ds.
(SECONDARY)
La grippe
tel. 14, 1911
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 1 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- Coul 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: C'erebro-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 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 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
Шитев M
(CITY OR TOWN.)
FULL NAME
.Registered No.
Place of 2
203 Shirley St Wencheok Mais
Death *
5
Death
19 ((
Residence
Widow of Owen gabbott
Age
.years.
.months.
4
days
STATISTICAL DETAILS
SEX
Female
COLOR
white
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
widow
MAIDEN NAME K
Harriet . W . Riley
HUSBAND'S NAME t
2
BIRTHPLACE$
Baldini me
NAME OF
FATHER
Stilman Riley
BIRTHPLACE
OF FATHER#
Baldini 2
MAIDEN NAME
OF MOTHER
Eliza ann. Stores
BIRTHPLACE
OF MOTHER +
Conway 21.1+
OCCUPATION
Dressmaker
INFORMANT §
Miss agness. as
Filed
19
Clerk
PLACE OF BURIAL OR REMOVAL U
hout Conway n.l+
DATE OF BURIAL
2/17
UNDERTAKER
C.R Bern
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Feb 11 19/
to. 7614 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 : General arteriosclerosis
.. (OURATION) ..
years
DAYS
Contributory :
.(OURATION).
3
DAYS
(Signed) ..
7615
1911
M.D.
(Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Translents, or Recent Residents.
How long at Place of Death ? ... years .. .................... months. ...................... days
Where was disease contracted,
If not at place of death ?.
* 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.
south vsorion
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
RETURN OF A DEATH Harriet. Wilson abbott
59
Date of
2/14
tel. 14, 1911
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Gregory Hloro
.Registered No ..
Place of 2
34 Havittorie Corr
Date of l
2/17
19 LC
Death
S
4
.months.
.days
STATISTICAL DETAILS
SEX
COLOR
white
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
married
MAIDEN NAME !! HUSBAND'S NAME +
BIRTHPLACE# Plymout one
NAME OF
FATHER
Daniel Stone
BIRTHPLACE
OF FATHER$
Lincoln Mais
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER #
Unity
One
OCCUPATION
Stationary Eugenia
INFORMANT § mi flore form ofdeceased
Filed
19
Clerk
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
2/19
1911
UNDERTAKER GR Bennem
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from 19 // to 70017 19/1 , 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 : Selenio Coronary arteries
.
(DURATION).
1
.. DAYS
Contributory :
General arteriosclerosis
indefinite
.(DURATION). . DAYS
31 Mutcall
M.D.
(Signed)
72619"
1941
(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 ?
* 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.
South vzorcon
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
Death *
S
Residence 10 15
Age
> 3
.years.
Feb. 17, 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 another of mars (No. 30 Semble Ane
Ellen A. Richardson
'FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] aRESIDENCE 30 Double Ane
PERSONAL AND STATISTICAL PARTICULARS
1
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
7069
191.1 ...
Feb 17
1917
to
If LESS than
1 day .....
hrs.
that I last saw her alive on
Feb-15
191.1 ... ,
-
and that death occurred, on the date stated above, at 3 30 am The CAUSE OF DEATH* was as follows : Pneumonia
(Duration)
yrs.
mos.
9
ds.
Contributory
(SECONDARY)
(Duration)
yrs.
mos.
ds.
B1 Metcall
M.D.
(Signed)
7617, 191
(Address)
winshop mass.
* 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 mazz levenna dora
DATE OF BURIAL
Je2 19.
1911
20 UNDERTAKER
ADDRESS
Filed 191 ..
REGISTRAR
Registered No.
3 SEX
female
4 COLOR OR RACE
5 SINGLE,
massed
MARRIED,
WIDOWED,
·
OR DIVORCED (Write the word)
(Month)
(Day)
(Year)
6 DATE OF BIRTH
Ang 24 1845
(Month)
(Day)
1
(Year)
7 AGE
6.5 yrs. 5 mos mos. 20 ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
at home
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Portsmouth S. A.
10 NAME OF
FATHER
Ceren Bragolon
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME
OF MOTHER
Am, H. Waldron
12 BIRTHPLACE OF MOTHER (State or country)
Porknowth N. H
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Author Neilson
(Address)
30 Purple Ane
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. ;..
Ward)
legit F. Brown, 124 Dovedeo to St
1917
Tel. 17,1911
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 engincer, 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 luborer, 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, peritonacum, etc., Carcinoma, Sar- coma, etc., of ... .. (name origin : "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (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 Alcoholismi, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
COMMONWEALTH OF MASSACHUSETTS.
RETURN OF A DEATH-1911.
CITY OF BOSTON.
FULL NAME Charles Blumberg
Registered No .. .. 1639
Place of Death
Boston
and Residence S
Date of Death
1911.
Age
31
.
years ..
.months.
6
.days.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
M
Maiden Name
Husband's Name
Birthplace
New York, N. Y.
Name of
Herman Blumberg
Father
Birthplace of Father
Russia
Maiden Name of Mother ...
Hannah Ratkowsky
Birthplace of Mother ..
Russia
Occupation Travelling salesman
Informant.
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from
1911, to
1911, 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:
ST
RAR'S
PATRIBU
,SIT DEL
CITY
Primary (Duration OFFICE
suicidal - during temporary
BOSTDNIA CONDITA ..
8 0 SREGI
MINE
N. MASS.
insanity
STO
Contributory : ( (Duration)
(Signed)
T Leary , Med .Ez.
M.D.
Feb. 17 1911
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal .. .
Brooklyn, J. Y. (Union Tield Cem)
Undertaker
L Jones & Con
Usual Residence
Winthrop (Millers Hotel)
Filed
Teb. 21
1911
A true copy.
Attest :
Registrar.
)
Carbolic acid poisoning -
TVITATI
18 80. NATA A
Feb.17
Hotel Essex
teb. 17,1111
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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop Mass
(No.
4 Pleasant-
St. ;...
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Ezargaret
· Gardner
Um B
Winthrop mass
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
FI
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Feliway
(Month)
199
(Dáy)
1911 (Year)
17 I HEREBY CERTIFY that I attended deceased from
191@ ..... , to
17
, 191/ .. .
that I last saw h
alive on
Fely
17
1916
and that death occurred, on the dato stated above, at ..
The CAUSE OF DEATH* was as follows :
acute cardiac dilititions and
having congestion of kidneys.
@ tourdiant.
.yrs.
mos.
Contributory
arterio - salario
(SECONDARY)
Several (Duration)
.yrs. ..
mos. .
.ds.
(Signed)
Fely 18
191/ .. (Address)
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.
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
Feb. 19, 191
15 Filed .. 191. ....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
6 DATE OF BIRTH
(Month) (Day)
7 AGE
68 yrs.
mos. ds.
or ........ min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
CC2 /touru
(b) General nature of industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
tuciny Cape Breton
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE OF FATHER (Státe or country)
Filmen Cape Breton.
12 MAIDEN NAME
OF MOTHER
mary In Forgal
13 BIRTHPLACE OF MOTHER (State or country) Pinar Salu Briton
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Man Yanderson
(Address)
14 Pleasant Iv
20 UNDERTAKER
An Dosthe Burke
ADDRESS
75 chambers 4
Bestin mass
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
Winthrop mar.
BOSTON (City or town.)
'FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
4 Pleasant St.
1
(Year)
If LESS than
day ......... hrs.
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.
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