USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 36
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continuerd
(SECONDARY)
way
(Duration) .. yrs.
.. mos. ds.
(Signed)
Surge Burgers Mangrach.
M.D.
(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 ..
In the
.. 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 July 8th 191
Filed .. , 191
REGISTRAR
5 SINGLE,
Single
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
If LESS than 1 day, ........ hrs.
or ....... min. ?
8 OCCUPATION
rather
(a) Trade, profession, or particular kind of work Pulisce Office
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Cambridge Mass
10 NAME OF
FATHER
Herbert & Gordon
andon
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Cambridge Abass
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
Cambrialas Moque
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Hubert & Sunday
(Address) 12/ Park An Withun Mask
30 UNDERTAKER
ADDRESS 116. Hampelpics
imar
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
3446 Winthrop (City or town.)
..... Ward)
[If death occurred in e hospital or institution, give its NAME instead of street and number.]
3 SEX
Male
4 COLOR OR RACE
White
MARRIED WIDOWED, OR DIVORCED (With the word)
6h
1 .yrs. 5 .mos. x ds.
191
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 questiou applies to each and evory 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 returu " 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 dutics 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 iu 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 frour 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, ctc.
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
1 PLACE OF DEATH
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH 281 (No. Main St. ;. ..
Winthroy BOSTON (City or town.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
'FULL NAME
Helen a. Frederick.
{If married or divorced woman or widow
give ·maiden name, also name of husband.]
Helen a mangun Caheinze Frederick
@RESIDENCE
281 Main at
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
female !brite
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widow
DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
80
yrs. - mos. ds.
8 OCCUPATION
(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
"Bighampton, N.C.
10 NAME OF
FATHER
albor Morgan
PARENTS
11 BIRTHPLACE OF FATHER (State or country
Sighampton N.Y.
12 MAIDEN NAME OF MOTHER Инфлагии
13 BIRTHPLACE OF MOTHER (State or country) Begkunstfor nl
14 THE ABOVE IS TRUE TO THE REST OF MY KNOWLEDGE
(Informant)
Helen B&euro
(Address)
18
Filed .. ... 191. ....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH July. 9 , 19111 (Year)
(Month)
(Day)
17
I HEREBY CERTIFY that I attended deceased from
to
March
191./ ...
July. 8
1911,
If LESS than
1 day .......
.. hrs.
that I last saw her alive on
191 / .,
or .......
.min. ?
and that death occurred, on the date stated above, at . 4 A. m.
The CAUSE OF DEATH* was as follows :
Senility.
. (Duration) ...
.yrs.
ayeara.
mos.
ds.
Contributory
(SECONDARY)
(Signed)
(Duration)
D.L. Jackson
mos.
ds.
M.D.
July 10, 1911 (Address),
5- 6 2 Shirley 80.
If death ffollowed injury or violence the certificate of death must be made out by tho 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 Winthrop2.
DATE OF BURIAL July 12 1911
20 UNDERTAKER Cell Vallvery
ADDRESSY Bastan
1
..
1
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 Ilouse- keepers who receive a definite salary), may be entered as Hlouscwife, 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) ; Mcasles ; Whooping cough; Chronic valvular heart discasc; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH 1 Wenthigh James Aller 2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Io. 20 Oceano CEur
St.
Ward)
(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
4 COLOR OR RACE White
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
7 AGE
If LESS than I day ..... ... hrs.
49 yrs. 3 mos. 2 .ds.
or .. min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
Superintendent
(b) General nature of industry, business, or establishment in which employed ( or employer) ..
Down Laborers
9 BIRTHPLACE
(State or country)
Leland
10 NAME OF FATHER
Solny Alvenu
PARENTS
11 BIRTHPLACE OF FATHER (Stato/or country)
Ireland
12 MAIDEN NAME OF MOTHER Ellent Saving
13 BIRTHPLACE OF MOTHER (State or country) Ireland.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Aux Alice ,Aber
(Address)
20 OVERNU VELUT
16
Filed. 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
IU, 19/1
(Month)
(Day) (Year)
THEREBY CERTIFY that I attended deceased from
1910, to July 1.2. 1911.
that I last saw him alive on 10, 1911. and that death occurred, on the date stated above, at.3.1º @m. The CAUSE OF DEATH* was as follows :
7,
(Duration) . Julenula
y/s.
mos. ds.
Contributory
(SECONDARY)
9
.. (Duration)
.yrs. mos. ..
ds.
(Signed) July 11 1/91) . (Address) 263 Winthing
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, CEMETERY
DATE OF BURIAL
July 13, 1911
20 UNDERTAKER
ADDRESS
79CUlantic It
., M.D.
3 SEX Male 6 DATE OF BIRTH Afval 8 , 1862 17 (Month) (Day) (Year)
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 ferer (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. . (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical' operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
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.
metcalf deslutar
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
Male
4 COLOR OR RACE
White
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
11
1911
1.
(Month)
(Day)
(Year)
7 AGE
.. yrs. mos. ds.
or ........ min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work.
(b) General nature of industry,
business, or establishment in
which employed (or employer)
Still form
(Duration)
.yrs.
mos.
ds.
Contributory
(SECONDARY)
.(Duration) YES. mos. ds.
(Signed)
M.D.
19 } ......
(Address).
(If death followed injury or violence the certificate of Heath 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.
In the
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
Holy Cross Miceldia
DATE OF BURIAL
Jeely 14.
191/
20 UNDERTAKER
ADDRESS voucher
F
191.
(Year)
(Month)
(Day)
?
I HEREBY CERTIFY that I attended deceased from 1
11
, 191.1 ...
19111.
If LESS than
I day,
hrs.
that I last saw him alive on
. 1911.
and that death occurred, on the date stated above, at
7 m.
The CAUSE OF DEATH* was as follows :.
Incidental to both
) BIRTHPLACE
(State or country)
10 NAME OF FATHERC John Boyer
PARENTS
II BIRTHPLACE OF FATHER (State or country)
2
12 MAIDEN NAME OF MOTHER Eliz abuck E. Daly
13 BIRTHPLACE OF MOTHER (State or country)
Busco
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed ... 191.
REGISTRAR
16 DATE OF DEATH
2 FULL NAME
[If married or divoreed woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Revere mass
BOSTON
(City or town.)
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 engincer, 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 Ilouscwife, 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, Broneho- 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 hcurt disease; Chronic interstitial nephritis, etc. The contributory (sccond- 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," " Collapsc," " 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- posurc, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholismi, etc.
1. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No. 51 Ingleseda Cnt St.
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
Month )
(Day)
11, 191
(Year)
17
I HEREBY CERTIFY that I attended deceased from
1910 ., to
July
"/ .. , 1918,
that | last saw h ....... alive on
July
8, 1911.
and that death occurred, on the date stated above, at .. S P m.
The CAUSE OF DEATH* was as follows : Fibro- cystic abdominal
about (Duration) ...
3 yrs.
mos.
ds.
Contributory.
(SECONDARY)
.. (Duration)
.. yrs. ..
mos. .
ds.
(Signed)
Que (2, 1911 (Address).
...
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
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