USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 30
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Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is " Epidemic cerebro-spinal meningitis ") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. . (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " 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.]
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