Town of Winthrop : Record of Deaths 1910-1912, Part 29

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 29


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 occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to eacli 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 Ilouse- 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, Ilousemaid, etc. If the occupation has been changed or given np 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 "Cronp") ; 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 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 nnknown, 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 Metall Hospital (No. Marching


St. ,


Ward)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX female


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


urdan


-


(Year)


7 AGE


If LESS than


I day, ... . , hrs.


52


. yrs.


7


mos.


24 ds


or ....... min. ?


8 OCCUPATION


(a)' Trade, profession, or


particular kind of work


-hrozne


(b) General nature of industry,


business, or establishment in


which employed (or employor)


9 BIRTHPLACE


(State or country)


Greensburgh. Pa


10 NAME OF


FATHER


Frank Robinson


PARENTS


11 BIRTHPLACE OF FATHER (Statc or country) Preteburgh Pa


12 MAIDEN NAME OF MOTHER Oliva Miltenberger


13 BIRTHPLACE OF MOTHER (State or country)


Puttelange Pa


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


Pertifield muss


Filed 191.


REGISTRAR


16 DATE OF DEATH


april 14'


(Month)


(Day)


191/ (Year)


17


I HEREBY CERTIFY that | attended deceased from


afil 8h


1911, to and 1x2


., 19 1/ ....... ,


that I last saw him alive on


, 1917. ...


afrl 142


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


The CAUSE OF DEATH* was as follows :


Pneumonia


(Duration) .


yrs.


mos.


6


ds.


Contributory (SECONDARY)


(Duration)


yrs.


mos. . ds.


(Signed)


31 Pul call


, M.D.


Com 15


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.


5 ds.


State


In the


yrs.


Where was disease contracted,


if not at place of death ?.


wwhp st . Walther


Former or


usual residence


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


1911


20 UNDERTAKER


ADDRESS


Glaff


'FULL NAME


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


Widow of


(City or town.)


Mary Stewart. Robinson


6 DATE OF BIRTH


august


(Month)


2/5/


(Day)


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 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., Carcinoma, Sar- coma, etc., of .. .. (name origin : "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart discase ; 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.


-


important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(No. 239 Court Road .


Grace Murphy


2 FULL NAME


{If married or divorced woman or widow


give maiden name, also name of husband. Twee white widow of michael


@RESIDENCE


339 Court Road


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


(Month)


(Day)


1


(Year)


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Alone


9 BIRTHPLACE


(State or country)


Freland


10 NAME OF


FATHER


Michael


11 BIRTHPLACE OF FATHER (State or country) Ireland


12 MAIDEN NAME OF MOTHER Olarak Opeil


1ª BIRTHPLACE OF MOTHER (State or country)


Ireland


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Mit & Carruth


(Address)


229 Court Road


Filed .. 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


april


(Month)


14


(Day)


, 1914


(Year)


17 I HEREBY CERTIFY that I attended deceased from


March


2


, 1911, to


april 14, 1911


If LESS than I day, .. hrs. that I last saw halive on april 13, 1911 and that death occurred, on the date stated above, at 10 Am. or .. min. ? The CAUSE OF DEATH* was as follows :


Cerebral apoplexy


(Duration) ..


.yrs. ..


2


mos.


ds.


Contributory


artínio sclerosis


(SECONDARY)


serune


.(Duration)


yrs. .


-ds.


(Signed)


april 14 1911 (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. .


mos.


ds.


Where was disease contracted, If not at place of death ?.


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL Foolywood


DATE OF BURIAL afr, 17. 1911


:0 UNDERTAKER


ADDRESS


Thor & Love Hi Morton


Ward)


....


Winthrop BOSTON


(City or town.)


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


3 SEX 6 DATE OF BIRTH 7 AGE PARENTS WHITE PLAINLT, WITH ONFADING INK THIS IS A PERMANENT NEvonD. (b) General nature of industry, business, or establishment in which employed (or employer)


yrs.


mos.


ds.


In the


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 Ilousewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.


Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is " Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia, Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- coma, etc., of .... (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronie 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," ctc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


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


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


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


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


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


N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very


important. See instructions on back of certificate.


PARENTS


12 MAIDEN NAME OF MOTHER Catherine .Mª Lavalin


13 BIRTHPLACE OF MOTHER (State or country) Ireland.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


John m Hagan


(Address)


24 Beal RM


16


Filed 191.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


april


(Month)


20


(Day)


1911


(Year)


17


I HEREBY CERTIFY that I attended deceased from


april. 6


191


, to apr.


20


1911


that I last saw her. alive on


191.1 .


14th


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


10 m.


The CAUSE OF DEATH* was as follows :


p


Pernicious anaEmia ,


(Duration)


1 yrs. +


mos.


ds.


Contributory


Mitral Insufficiente


.++


(SECONDARY)


(Duration)


. yrs.


mbs.


ds.


(Signed)


april 21


1911 (Address).


7 Central An.


* 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).


In the


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


DATE OF BURIAL


Holy Cross, Holder April 23, 1911.


20 UNDERTAKER


ADDRESS


49 Maverick


7


BOSTON


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Famale


4 COLOR OR RACE


White


5 SINGLE,


Single


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


(Month)


(Day) (Year)


7 AGE


58


.yrs.


mos.


ds.


or min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work.


Hat Maker


(b) General nature of industry,


business, or establishment in


which employed (or employer)


9 BIRTHPLACE


(State or country)


East Cambridge.


10 NAME OF


FATHER


Peter A. Kivlan


11 BIRTHPLACE OF FATHER (State or country) Ireland.


1


RA APR 25 191


1 PLACE) OF DEATH Winthrop


The Commonwealth of Massachusetts " STANDARD CERTIFICATE OF DEATH ( No 24 Real


2 FULL NAME. Mary Elizabeth Milan [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 24 Beal St Winthrop.


St. :


Ward)


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


If LESS than 1 day, .. hrs.


-


M.D.


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthifulness 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, Farme / 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 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, Ilousemaid, 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, peritoneum, etc., Carcinoma, Sur- 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-pucumonia (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.


important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1.PLACE OF DEATH


.. (No .....


40 Willow are


St. ;


(City or town.)


Ward)


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


Hannah. Ellen Gardner 'FULL NAME


widow of Chaos. R. Gardner


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE to willow and whichit Isa Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


this


(Month)


(Day)


22,


1916 (Year)


17 I HEREBY CERTIFY that I attended deceased from Au, 18, 191/ .. , to


Ahy. 24.


1911.


that I last saw her alive on


Ahs. 22,


. , 191 4.,


and that death occurred, on the date stated above, at .4/5 m.


The CAUSE OF DEATH* was as follows :


Pneumound


.(Duration)


.yrs.


mos.


4


ds.


Contributory


La Suppe -Haut.


(SECONDARY)


(Duration)


yrs.


mos. .


ds.


(Signed) .


Albert B. Looman


.. , M.D.


apr . 25


1911.


(Address)


NurThiof 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.


In the


ds.


State


.yrs.


mos ..


ds.


Where was disease contracted, if not at place of death ?


Former or usual residonce


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


afinic 25


.,


191(


20 UNDERTAKER


le RIBereso-


ADDRESS


Filed. .. 191 ..


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Wedon


(Month)


(Day)


1833


(Year)


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


73 yrs. 9 mos.


26


. ds.


or


. min. ?


at Home


2


9 BIRTHPLACE


(State or country)


Bradford mais


10 NAME OF


FATHER


Mores. E. Func


11 BIRTHPLACE OF FATHER (State or country) Bradford.


12 MAIDEN NAME


OF MOTHER


annie. W. Bailey


13 BIRTHPLACE OF MOTHER (State or country)


west newbury. leess.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


cc-


REGISTRAR


3 SEX 6 DATE OF BIRTH 7 AGE 8 OCCUPATION (a)' Trade, profession, or particular kind of work PARENTS WHITE PLAINLY, WITH UNTADING INA ID ID A TEAMANENNT NEUUND. (b) General nature of industry, business, or establishment in which employed (or employer).


4 COLOR OR RACE


volante


24


apr . 22, 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 laborer, Laborer- Coal mine, etc. Women at hiome, who are engaged in the duties of the household only (not paid Ilouse- 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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