Town of Winthrop : Record of Deaths 1910-1912, Part 39

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 39


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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Winthrop


(No.


80


Jutman


St. ;


Ward)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


'FULL NAME


[If married or divorced woman or widow


give maiden name, also name of) husband.]


@RESIDENCE


80 tutulan


3 SEX


Female


4 COLOR OR RACE


Mlute


6 DATE OF BIRTH


March


(Month)


17


(Day)


7 AGE


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


(b) General nature of industry,


business, or establishment in


which employed (or employer).


10 NAME OF


FATHER


John le lack.


PARENTS


1ª BIRTHPLACE


OF MOTHER


(State or country)


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


61


yrs.


4


mos.


16. ds.


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Married


1850


17


-


(Year)


or .


min. ?


9 BIRTHPLACE


(State or country)


St. Johns Arefoundland


11 BIRTHPLACE OF FATHER (State or country) St. Johns Newfoundland


12 MAIDEN NAME OF MOTHER Elizabeth Hogan


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


margenet S. Leggins


(Address)


Id Putinand St


18 Filed. 191 .. ....


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


any


3d


1911


(Month)


(Day)


(Year)


HEREBY CERTIFY that I attended deceased from


1908, to


any 39


1911


If LESS than


I day, ......


hrs.


that I last saw h M alive on


191 1 .


and that death occurred, on the date stated above, at 2 45 qm.


The CAUSE OF DEATH* was as follows : Cerebral Halmorage


.(Duration)


2 yrs.


mos.


ds.


Contributory (SECONDARY)


(Duration)


.yrs


Brott call


mos.


ds.


, 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.


In the


ds.


State


.... yrs.


mos. .


ds.


.........


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


Former or usual residence ..


1 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


Calvary Cena Slanciata Cluq 5, 191.


ADDRESS


20 UNDERTAKER Freah A magiathe East Anton


.. (City or town.)


Sarah Ann Diggins wife of Patricle Deggine


.


(Signed)


any 39


1911


(Address)


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.


1


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.


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


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


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


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


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


-----


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


important. See instructions on back of certificate.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH -


(No.


2.37


Shirley


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


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


10 (Month)


18


(Day)


(Year)


7 AGE


71 yrs.


9 mos.


15.05.


Or ....... min. ?


8 OCCUPATION


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


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


' BIRTHPLACE


(State or country)


10 NAME OF


FATHER


Jonas white


PARENTS


11 BIRTHPLACE OF FATHER (State or country) 5) queleon U.H.


12 MAIDEN NAME OF MOTHER Marquito Cla. Fr.


13 BIRTHPLACE OF MOTHER (State or country)


" THE ABOVE IS TRUE TO THE BEST OF' MY KNOWLEDGE


(Informant)


(Address)


2.39 Strimler SX


REGISTRAR


16 DATE OF DEATH


august


3


(Month)


(Day)


, 19 !! (Year)


I HEREBY CERTIFY that I attended deceased from


1909. to.


3


, 1911 .,


, 191 ' , and that death occurred, on the date stated above, at//Am. The CAUSE OF DEATH* was as follows :


Cachal afopenly .(Duration) 3


mos. ..


ds.


antónio salueres


Contributory ..


(SECONDARY)


(Duration)


mos. ..


ds.


O.Salmon


M.D.


(Signed)


aug 3, 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.


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


1), 1911


20 UNDERTAKER


ADDRESS


Filed , 191


If LESS than 1 day, .. . hrs. that I last saw him alive on 3


(City or town.)


Francislotris 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 937 Hurley SX.


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 usc 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 ; Chronie 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 street, or one supposed to be due to Alcoholism, etc.


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


3 SEX 7 AGE PARENTS 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 N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state - (Address)


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


I PLACE OF DEATH -


(No.


5 Cottage RK Kg.


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


Harper Dr. 21. C. Roy


BOSTON (City or town.)


Ward)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


COLOR OR RACE


W


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED 11LLC


(Write the word)


6 DATE OF BIRTH


5-


14


, 197


17


(Month)


(Day)


(Year)


If LESS than I day, hrs.


55 yrs ..


2. mos.


20ds.


or


min. ?


8 OCCUPATION


at Home,


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


9 BIRTHPLACE


(State or country)


91.4.


10 NAME OF FATHER Roby Harhun.


11 BIRTHPLACE OF FATHER (State or country)


12 MAIDEN NAME OF MOTHER


13 BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


. (Informant)


The, Kry


5 Cack due Dil RS


.... REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


I HEREBY CERTIFY that I attended deceased from


19.00 191


to


Cung. 4


., 1915,


that I last saw h /4 alive on


, 191/ .,


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


1 P .m.


m.


The CAUSE OF DEATH* was as follows :


E op. gastre


.(Duration)


Idifutamo


mos.


ds.


Contributory.


(SECONDARY)


Conte Dianlam & Cardin


(Duration) yrs.


mos.


4 ds.


(Signed) .


, M.D.


260 E Eagles EB 191 / . (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


Cremation EH8-


. 191/


ADDRESS


.. , 191


20 UNDERTAKER


9h. C. Spacer


(Month)


(Day)


. 191.1


(Year)


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


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.


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.


١


THE COMMONWEALTH OF MASSACHUSETTS


-makej.com RETURN OF A DEATH


(CITY OR TOWN.)


FULL NAME Mable Gertrude Broughton Roche


Place of


2


metcalf


Hospital Winthrop


Death *


Residence


36 Bellemare Que. Winthrop


Age


29


.. years.


2


.months.


26


... days


STATISTICAL DETAILS


SEX


COLOR


SINGLE, MARRIED, WIDOWED, OR DIVORCED


MAIDEN NAME T


mable Sistunde Broughton


HUSBAND'S NAME +


arthur C. Roche


BIRTHPLACE#


Malden mask.


NAME OF


FATHER


William J. Broughton


BIRTHPLACE


OF FATHER#


Providence R.J.


MAIDEN NAME


OF MOTHER


Francis J. James


BIRTHPLACE


OF MOTHER $


Providence R.J.


OCCUPATION


House Wife


INFORMANT §


arthur & Roche


PLACE OF BURIAL OR REMOVAL I


Stonington bonn.


DATE OF BURIAL


Dug 5th


.74.19 //


ADDRESS


UNDERTAKÉR


Chas R. Bennison Anthrop


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last


to


any


illness, from ..


July 314


19


5


.19 )


-


that to the best of my knowledge and belief death occurred on the


date stated above, and that the CAUSE OF DEATH was as follows :


Primary :


Small


acute obstruction of Intestine


Unknown disease.


0


.(DURATION)


5


.. DAYS


Contributory :


.(DURATION).


.. DAY8


(Signed)


M.D.


ay


5


19 l/ (Address)


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


How long at


Place of Death ?


years.


months.


2


.. days


Where was disease contracted,


If not at place of death ?


36 Bellww are Winthrop Los


Filed


19


Clerk


* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If in a Hospital or Institution, give its NAME Instead of street and number.


t In case of married or divorced woman, or widow.


# State or country ; also city, town or county, If known.


§ Name and address of person giving statistical details. || Name of cemetery.


GyOPEN INANYWYRA V SI SIHI- 'YNI HLIM 100 111


ALL NAMES TO BE IN FULL


Registered No.


Date of


aug F.


1911


Death


5


.......


Augus! !


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 Winthrop (No. 31 Hawthorne St. ; Ward)


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


Forsell, Wharf Osgood FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 31 Hawthorne Slut


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX mak


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


mamed


6 DATE OF BIRTH


Tum (Month)


22


1881


(Day)


(Year)


7 AGE


60


yrs. ... mos. 27


ds.


or .. min. ?


8 OCCUPATION


(a)' Trade, profession, or


particular kind of work


Manager


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


Wholesale Buef Cc


9 BIRTHPLACE


(State or country)


Hasta man


PARENTS


12 MAIDEN NAME


OF MOTHER


In alaley Wharf


18 BIRTHPLACE


OF MOTHER


(State or country)


Savona ml


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Commin .E. Cs good


(Address)


16 Filed 191.


REGISTRAR


(Duration)


yrs. .


mos.


ds.


Contributory


(SECONDARY)


. (Duration)


6


yrs. .


mos. .


ds.


(Signed)


..


9 Stewar


.. .


M.D.


auftr1, 191


(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. .


... 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


any 12


191 7


20 UNDERTAKER


ADDRESS


wandust


191.


(Year)


17


I HEREBY CERTIFY that I attended deceased from


1905


to


191).


If LESS than


I day, ...


hrs.


that ! last saw him


alive on


angs


1911 .,


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


11 p.m.


The CAUSE OF DEATH* was as follows :


Renal cuffia


dermine Bruglato


10 NAME OF


FATHER


Stephen Os good


11 BIRTHPLACE OF FATHER (State or country) Gardner me


16 DATE OF DEATH


auft. 9th


(Month)


(Day)


-


STANDARD CERTIFICATE OF DEATH. 0


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-


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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.




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