USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 39
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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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