Town of Winthrop : Record of Deaths 1910-1912, Part 30

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 30


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).


Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93 | Part 94 | Part 95


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," " 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 discases 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.


FULL NAME


Louisa M Bell


Registered No ....


3257


Place of Death ¿ Boston


and Residence S


Date of Death


Apr.4


1911.


Age


44


years


4


months


26


days.


STATISTICAL DETAILS.


SEX F


COLOR Col.


SINGLE, MARRIED, WID., DIV. Div.


Maiden Name. .


Husband's Name


Birthplace


--- --- N.S.


Name of


William Bell


Father


Birthplace of Father.


ITova Scotia


Maiden Name Sarah J.Mitchell


of Mother .


Birthplace of Mother


Ilova Scotia


Occupation


At Home


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:


AR'S


PATRIBUS. SIT DE !!


CITY.


&


BOS-PDN.I.A. CONDITAA


ITATIS


DONATA A


B O.S. 18 3D. SREGIMINE TON. MASS.


Contributory : ( (Duration)


(Signed)


B Hollings


M.D.


Apr. 5


1911


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


In hospital 11 dys


Place of Burial or removal.


Lynn"Pine Grove"


E A Mover


Undertaker


Lynn


Usual Residence


Winthrop( 64 Prospect avc)


Apr. 6


1911


Filed


A true copy.


Attest :


ErMSlenen


Registrar.


Chr .Nephritis - 5 yrs


Primary (Duration)


Mass . Gen. Hostt .


april 2+ 1711


1


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


· 1 PLACE OF DEATH


Shirttrop Maza ( No.


90 atlantic St


St. ;..


John a. Olsen.


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


90 allautic St. Truthof Maso


(City or town.)


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


16 DATE OF DEATH


april


(Month)


28


(Day)


., 19!1. (Year)


,


871


(Year)


17


I HEREBY CERTIFY that I attended deceased from


4/20


4


27


191\ , to ...


, 1913 ,


If LESS than


day, .


hrs.


that I last saw h. w alive on.


4/27


, 1911


and that death occurred, on the date stated above, at. 4 Am.


CAUSE OF DEATH* was as follows :


Mary Tuberculosis


(Duration) 7 yrs.


mos. .. ds.


Contributory. (SECONDARY) 2


.. (Duration)


mos. ... „ds.


(Signed) 4/30 ,1911


., M.D.


(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


DATE OF BURIAL


Cremated Facuta 5-/-, 191%


20 UNDERTAKER Dr.C. Saqqv


ADDRESS


Filed. 191


REGISTRAR


Registered No.


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


or .... . min. ?


(a) Trade, profession, or


particular kind of work


Parsinga Elevator


9 BIRTHPLACE


(State or country)


faxline. ICC-


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


3 SEX 4 COLOR OR RACE white Tale 6 DATE OF BIRTH 9 16 (Month) (Day) 7 AGE 8 OCCUPATION (b) General nature of industry, business, or establishment in which employed (or employer) 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (State or country) 12 MAIDEN NAME OF MOTHER PARENTS 13 BIRTHPLACE OF MOTHER (State or country) Sweden. (Informant) important. See instructions on back of certificate. (Address) 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 39. yrs. 7 mos. 12 ds.


-


ʻ


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 - 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 (retircd, 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, 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 strect, or one supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as _1 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


13 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


3 SEX


Anche


4 COLOR OR RACE


§ SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


marie


6 DATE OF BIRTH


14


1562


17


(Month)


(Day)


(Year)


7 AGE


If LESS than day, .. hrs.


or ....... . min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Clerk.


(b) General nature of industry,


business, or establishment in


which employed (or employer)


-Gunand J. S. Lim


(Duration).


.yrs.


mos.


ds.


Contributory (SECONDARY)


(Duration) .yrs. ..


mos. ds.


M.D.


quit30, 191


(Address)


MEDICAL EXAMINER


* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.


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 Walkof Mars


DATE OF BURIAL


May 2


191 €


....


20 UNDERTAKER


ADDRESS


Quillota


3206 Winthrop (City or town [If death occurred in a hospital or institution, give its NAME instead of street and number.]


1 PLACE OF DEATH writing (No. 29 Plummer and St. : Ward)


William


H James 1


2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 29 Plummer save.


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


16 DATE OF DEATH


apue


1:30, 191


(Day)


(Year)


Month)


I HEREBY CERTIFY that I have investigated the death of the deceased.


The CAUSE OF DEATH* was as follows :


Poisonnia by illumin


ating gas, accidental


9 BIRTHPLACE


(State or country)


Portland me


10 NAME OF FATHER John. Cameron


(Signed)


Senza Burgers Magrath,


11 BIRTHPLACE OF FATHER (State or country)


49 yrs. 3 mos. 16 ds.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


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., 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. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident ; Revolver wound of head -homicide ; Poisoned by carbolic acid - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of " Contributory."


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.


FULL NAME


Jennie I Blair


Registered No ... 4221


New England Deaconess Hospt.


and Residence S


Date of Death


May1


.1911.


Age


.70


years


11


months


7


.days.


STATISTICAL DETAILS.


SEX


COLOR


SINGLE, MARRIED, WID., DIV.


F


W


Carruthers


Maiden Name


Isaac Blair


Husband's Name .


Birthplace


New Annan, P . E.


Name of


Christofer Carruth


Father


Birthplace of Father


Scotland


Contributory : 2 (Duration)


Maiden Name


Jane Irvin


of Mother .


Birthplace of Mother ..


Scotland


Occupation


At home


Informant ..


Place of Burial or removal ..


'inthrop"Winthrop Cem


C R Bennison


Undertaker


Winthrop


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:


STRAR'S


FRIBL


PA


CITY.


,SIT DEL PrimaPx (Duration)


Carcinoma of stomach, laparotomy


YSICE


1yr:


1 .mo.ll dys


CIVITATIS


BOSPDNI.A. CONDITAA


RESMINI DUNATA A 4.SS.


STON


(Signed)


D. F. Jones


M.D.


May 1


1911


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


In hospital 1 mo 17 dys


Winthrop( 36 Prospect sve)


Usual Residence


iLay 3


Filed 1911


A true copy.


Attest :


Registrar.


Place of Death } Boston


may 1,1911


-


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.


PARENTS


11 BIRTHPLACE OF FATHER (State or country)


Den Stand


12 MAIDEN NAME OF MOTHER


13 BIRTHPLACE OF MOTHER (State or country)


Bucon-


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


159 UmcheSia


16 Filed


_, 191 ..


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


3 SEX


female


4 COLOR OR RACE


Muito


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Singer


6 DATE OF BIRTH


(Month) (Day)


(Year)


7 AGE


74 yrs.


mos. ds.


or min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work.


at home


natural e ames . probably heart disease.


mos. ds.


Contributory


(SECONDARY)


(Duration)


yrs.


mos. ds.


(Signed)


M.D.


May4.


191[


(Address)


MEDICAL EXAMINER


* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.


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 1


1916


30 UNDERTAKER


ADDRESS


URBemusa


3212 Winthrop (City or town.)


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


2 FULL NAME Susan L. Jeksburg {If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 205 Pleasant


PERSONAL AND STATISTICAL PARTICULARS


winthrop


Registered No.


16 DATE OF DEATH


may


(MonthY


(Day)


1911 (Year)


17 . I HEREBY CERTIFY that I have investigated the death of the deceased.


If LESS than


[ day, ...


hrs.


The CAUSE OF DEATH* was as follows :


(b) General nature of industry,


business, or establishment in


which employed (or employer)


9 BIRTHPLACE


(State or country)


10 NAME OF


FATHER


abijah. R. Towleshuy


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH winthrop (No. 205 Pleasant St. : Ward)


0


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, 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 deatlı), 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. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head-homicide ; Poisoned by carbolic acid - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of " Contributory."


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.


15


Filed. 191.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


M


(Month)


5


(Day)


19/11 (Year)


17


I HEREBY CERTIFY that I attended deceased from


Mar 16h


1911


...


to


., 191 .).,


-My


that I last saw hey


alive on


, 191 / .


and that death occurred, on the date stated above, at 8.45 9.


The CAUSE OF DEATH* was as follows :


Perforated appendix


operation


.. (Duration)


yrs. .


mos.


16


ds.


Contributory (SECONDARY)


(Signed)


6


(Duration)


mos. .


yrs.


ds.


B15 metcall


, 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.


11 ds.


In the


State


. . yrs.


mos.


Where was disease contracted,


If not at place of death ?.


15/fichero St with 1 mm


Former or


usual residence.


10 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


.


191.4


20 UNDERTAKER


ADDRESS


(City or town.)


Ward)


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




Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.