Town of Winthrop : Record of Deaths 1910-1912, Part 27

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 27


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Dr. Johnson


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 stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " All- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," " Old age," "Shock," " Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


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


Minthof (No. 44. Buchanan


St. ;...


Ward)


[If death occurred in a hospital or institution, give its NAME instead of street and number.]


2 FULL NAME Susana Braku Collins.


[If married or divorced woman er widow give maiden name, also name of husband.] @RESIDENCE HH Buchanan St Shin Chan/ Quasi


PERSONAL AND STATISTICAL PARTICULARS


4 COLOR OR RACE


white


5


SINGLE,


MARRIED,


WIDOWED,


OR DIVORCER


(Write the word) awad


& DATE OF BIRTH 1 18 (Day)


(Month)


71 yrs. - mos. 29 ds.


or .. ... min. ?


(a) Trade, profession, or


particular kind of work


at home.


(b) General nature of industry. business, or establishment in which employed ( or employer)


10 NAME OF


FATHER


Bartholomew @ Gr


11 BIRTHPLACE OF FATHER (State or country)


12 MAIDEN NAME OF MOTHER


Jours mars


Susannah Hopkins


puno Mars-


7


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


Fb 17 h


(Month)


(Day)


19! 1


(Year)


. 1840 17 I HEREBY CERTIFY that I attended deceased from (Year) 726 8ª , 191./ , to 7.617 1


, 191 } ,


that I last saw her


alive on.


70017


, 191 ] ,


and that death occurred, on the date stated above, at ...


1 pm.


The CAUSE OF DEATH* was as follows :


Pneumunng


(Duration)


yrs. .


mos. ..


9


ds.


Contributory ... (SECONDARY)


yrs. (Duration) 6315 Meterall mos. . ds. M.D.


(Signed)


7619


1913.


* 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


2-19-1911


ADDRESS


20 UNDERTAKER


H.C. Skaago.


( Address)


(City or town.)


Susan B. how John Collins


Registered No.


3 SEX Female 7 AGE 8 OCCUPATION PARENTS WITTE PEAINTET, WITTY ONTADING INK ITIS TO A PERMANENT NEVOND. 9 BIRTHPLACE (State or country)


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, Loeo- 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 _It 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 affectiou 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, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant ueoplasms) ; 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 casing 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 supposedto be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


THE COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH


(CITY OR TOWN.)


FULL NAME Lois Knowles. Blake Hathaway


.Registered No.


Place of )


Death *


S


55 themandSt


Residence


Age


94


.years.


months.


days


STATISTICAL DETAILS


SEX female


COLOR


white


SINGLE, MARRIED, WIDOWED, OR DIVORCED


MAIDEN NAME


Pois Kunales. Blake


HUSBAND'S NAME t


Filmes Hathaway


BIRTHPLACE #


Compton 11. H.


NAME OF


FATHER


Envoli. Jackson Blake


BIRTHPLACE


OF FATHER#


MAIDEN NAME


OF MOTHER


Marcin Every


BIRTHPLACE


OF MOTHER #


OCCUPATION


INFORMANT §


Care. V. Hathaway


PHYSICIAN'S CERTIFICATE


HEREBY CERTIFY that I attended deceased during last illness, from Jolly 27 19// to man 3 .. 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 : Double Primaria


(DURATION).


4


.DAYS


Contributory :


Senility


.(DURATION) ......... DAY8


(Signed)


Johnson


M.D.


(Address).


SPECIAL INFORMATION only for Hospitais, Institutions, Transients, or Recent Residents.


How long at


Place of Death ?


.years


.. months .. ...................... days


Where was dlsease contracted,


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, 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.


FILL OUT WITH INK. - THIS IS A PERMANENT RECORD


ALL NAMES TO BE IN FULL


PLACE OF BURIAL OR, REMOVAL II


DATE OF BURIAL


315


19 ‹ ‹


UNDERTAKER


ADDRESS


Date of ¿


Ixar 3


19 /7


Death


S


26


March 3, 19


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


.


(No ..


20 Jevac


St. :..


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 mali 6 DATE OF BIRTH


4 COLOR OR RACE


White


1 10


(Month) (Day)


-


(Year)


7 AGE


If LESS than I day, ... .. hrs.


70 yrs. 2 mos .. Lí ds.


or .. min. ?


8 OCCUPATION


(a) Trade, profession, or particular kind of work .. machinist,


(b) General nature of industry, business, or establishment in which employed (or employer).


9 BIRTHPLACE


(State or country)


Pensylvania.


10 NAME OF


FATHER


Vibia B. Smith


PARENTS


12 MAIDEN NAME OF MOTHER


Per


Me Laughlin


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


March


(Month)


14 (Day)


, 19: 11 (Year)


I HEREBY CERTIFY that I attended deceased from


March


9


19/11 to March 14, 1911,


that I last saw himalive on


Brauch 14, 1911,


and that death occurred, on the date stated above, at. 2 . 25P.m.


The CAUSE OF DEATH* was as follows :


Hyper-static Aneumonia


.(Duration)


yrs.


mos. ...


6


ds.


Ingreanditis - Senility


Contributory ..


(SECONDARY)


aseara.


.(Duration)


yrs.


mos.


ds.


(Signed)


D. L. Jackson


M.D.


March 14, 1911 (Address)


562 Shirley 89.


* If death followed injury or violence the certificate of death must be made out by the Medical Examiner. Winthrop.


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 good Lawn


DATE OF BURIAL


3-17. 191/


ADDRESS


20 UNDERTAKER


It.C. Skaggs


(City or town.)


Ephraim Smith.


2 FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


married


1841


17


11 BIRTHPLACE OF FATHER (State or country)


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tiou 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, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But iu many cases, especially in industrial employmeuts, 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- mun, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked ou 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 ('AUSING 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 causatiou), using always the same accepted term for the sam 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, Sur- coma, etc., of .. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection ueed not be state ? unless im- portaut. 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.


COMMONWEALTH OF MASSACHUSETTS.


RETURN OF A DEATH-1911.


CITY OF BOSTON. 2678


FULL NAME


Anna M Walsh


Registered No ..


2 Mt. Vernon st


Place of Death ¿


Boston


and Residence S


Date of Death


Mar. 17


1911. Age 56


years


months


14


days.


STATISTICAL DETAILS.


SEX


COLOR W


SINGLE, MARRIED, WID., DIV. W


Maiden Name


Doherty


Michael Walsh


Husband's Name


Arlington


Birthplace


Name of


Mathew Doherty


Father


Birthplace of Father


Ireland


Maiden Name Ann Coleman


of Mother


Birthplace of Mother


Ireland


Occupation


Housekeeper


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 Primary (Duration)


Heart dis. - 3 yrs


CITY


CTYTTATI


BOSTDNIA- CONDITA MA


A 1822


IBED.


DONATA A


MASS.


Contributory : 2


Ac.Indigestion -2 hrs


(Duration)


(Signed)


D.McIntyre


M.D.


Mar.17 1911


SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.


Place of Burial or removal ..


Calvary ( New)


C V Russell


1911


Undertaker


Usual Residence


Winthrop Hds( 79 Cliff ave)


Filed Mar. 23


A true copy.


Attest :


ENMSlenen


Registrar.


B ISREGIN


BOSTON


IMIN


F


anna My. Walsh Mar 17, 1911.


THE COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH


(CITY OR TOWN.)


FULL NAME


Florence Lillian Pretoria Black


Registered No.


Date of ¿


inew 2.5


19 '(


Death


S


11


months.


13


.days


STATISTICAL DETAILS


SEX


female


COLOR


white


SINGLE, MARRIED, WIDOWED, OR ( DIVORCED


MAIDEN NAME t


HUSBAND'S NAME +


BIRTHPLACE $


Sussex


England


NAME OF


FATHER


Seo. A. Black


BIRTHPLACE


OF FATHER+


Staplus U.B.


MAIDEN NAME


OF MOTHER


Mary Dlembeck Saunders


BIRTHPLACE


OF MOTHER+


OCCUPATION


INFORMANTS


teacher


Seo. A. Black.


Filed


19


Clerk


PLACE OF BURIAL OR REMOVAL I


DATE OF BURIAL


3/25


19 (r


UNDERTAKER


ADDRESS


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last illness, from mich 19 19 /


to .. Ich23/197. 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 :


malignant Diphtheria


(DURATION).


.DAYS


Contributory :


... (DURATION) .... .. DAYS


(Signed)


M.D.


Mich 2 5011


(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 detalls. I/ Name of cemetery.


FILL OUT WITH INK. - THIS IS A PERMANENT RECORD


ALL NAMES TO BE IN FULL


Place of


93 Count Down


Death *


5


Residence


marchiol


Age


/ 0


.. years.


Florence L. P. Black ~ Mar. 23, 1911.


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 (No ... 198 Circuit Road St. ; Ward)


Winthrop BOSTON


(City or town.)


[If death occurred in a hospital or institution, give its NAME instead of street and number.]


mark alfred Whitehead


2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 158 Circuit Road Winthrop


PERSONAL AND STATISTICAL PARTICULARS


3 SEX m


4 COLOR OR RACE


w


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Single


6 DATE OF BIRTH


(Month)


(Day)


1


(Year)


7 AGE


If LESS than I day, . .. .. hrs.


ds.


or


min. ?


(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) Winthrop Mass.


10 NAME OF


FATHER


mark Whitehead


PARENTS


11 BIRTHPLACE OF FATHER (State or country) Bastón


12 MAIDEN NAME OF MOTHER


annie Sullivan


13 BIRTHPLACE OF MOTHER (State or country) East Bastan


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


mark Whitehead


(Address)


155 Circuit Rd Win.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH Mar. 25


(Month)


(Day)


191.1


( Year)


17 I HEREBY CERTIFY that I attended deceased from


, 191


, to


Mar. 25, 1911.


that I last saw heno


Mar. 25,


, 191.2.,


and that death occurred, on the date stated above, at .... P.m.


The CAUSE OF DEATH* was as follows :


Diphtheria


yrs. . ..... .. mos. ds.


(Duration) . General infection. .


Contributory


(SECONDARY)


.(Duration) .


yrs. . mos. .. .ds.


Albert Boorman


M. D.


NaThrop Mais


* 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


Holy Cross


DATE OF BURIAL


march 27, 1911


20 UNDERTAKER


ADDRESS


J.J. Land & D. H. Land 120 Have St E. B.


WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.


Filed .. 191


8 OCCUPATION 3 yrs. . 6 mos. 28


(Signed)


3/26- 1911. (Address)


Registered No.


March ,


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 liue 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) Forcman, (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, Laborcr - 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 eutered 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 ('AUSING 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 .. (namo origin: "Cancer " is less definite ; avoid use of " Tumor" for malignaut neoplasms) ; Measles; Whooping cough ; Chronic valvular heart disease ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless in- 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," "Convulsious," "Debility " ("Congenital," "Seuile," 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:




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