Town of Winthrop : Record of Deaths 1910-1912, Part 41

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 41


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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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. 58 Orlando On Est. :


Ward)


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


'FULL NAME.


Frank . Alger.


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 58 Orlando art. Minthaofa


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED


OR DIVORCED


(Write the word)


Single


6 DATE OF BIRTH


De. (Month)


19 (Day)


(Year)


7 AGE


33


yrs.


8


mos.


-ds.


If LESS than I day, .... hrs.


or ... .min. ?


& OCCUPATION


(a)' Trade, profession, or


particular kind of work ....


Books bufree.


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


9 BIRTHPLACE


(State or country)


Gingham 2


PARENTS


11 BIRTHPLACE OF FATHER (State or V. Breda water mars.


12 MAIDEN NAME OF MOTHER


Catherine higgins


13 BIRTHPLACE OF MOTHER (State or country)


Unknown.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


2. IL. Townsend


(Address)


58 Orlando anc.


REGISTRAR


16 DATE OF DEATH


aug.


21


.


1911


(Month


(Day)


(Year)


I HEREBY CERTIFY that I attended deceased from


aug 13 th


1911


any 21, 1911.


to


that | last saw h. L.


alive on


any 21


, 191 \ .,


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


4 P.m.


The CAUSE OF DEATH* was as follows :


Hemorrhage from Bronchi;


(Duretion)


yrs.


mos.


ds.


Contributory


Injury to cheat from face


(SECONDARY) thick wales ago


(Duration)


yrs. .


mos. ds.


(Signed)


r. a. morrison


M.D.


aug. 22, 1911


. (Address)


80 Princeton At.


* 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).


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.


mintup In years


19 PLACE OF BURIAL OR REMOVAL lling ham man.


20 UNDERTAKER


E. G. BROWN & SON,


DATE OF BURIAL,


ADDRESS


Filed ... 191.


BOSTON


(City or town.)


Registered No.


1877


17


10 NAME OF


FATHER


Charles It.


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 necdcd. As examples: (c) Spinner, (b) Cotton mill; (a) Sales- mun, (b) Grocery ; (a) Forcman, (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 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 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 iutercurrent) 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.


PARENTS


I1 BIRTHPLACE OF FATHER (State or country)


Pensia


12 MAIDEN NAME OF MOTHER millie philips


13 BIRTHPLACE OF MOTHER (State or country)


new york City


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Strather


(Address)


Filed 191


REGISTRAR


16 DATE OF DEATH


Cluj. SC.


(Month)


(Day)


1911


(Year)


17


I HEREBY CERTIFY that I attended deceased from


191, to


, 191


1


that I last saw h


alive on ..


, 191


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


m.


The CAUSE OF DEATH* was as follows :


Still Born


.... (Duration)


yrs. .


.mos. ..


ds.


Contributory. (SECONDARY)


(Duration) .. yrs.


mos. . ds.


(Signed)


, M.D.


Qua


29/0/


(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 ...


2) Thedent ave


19 PLACE OF BURIAL OR REMOVAL Hiturn e heltnoch


20 UNDERTAKER


Daoch Standthe


... Ward)


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


2 FULL NAME Habe Berimpan


[If married or divorced woman or widow


give maiden name, also name of husband.Y


@RESIDENCE


2% gui dent


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX filmale


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


(Month)


(Day)


(Year)


7 AGE


If LESS than 1 day, .. .. hrs.


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).


9 BIRTHPLACE


(State or country)


printreja mais


10 NAME OF FATHER Clearbey Berman


> Fintof2 mod


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


) PLACE OF DEATH ʼ


Mirentin mass. (No. .. 1


St. ;


BOSTON (City or town.)


DATE OF BURIAL aug 27. 191


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 ifome, who are engaged in the duties of the household only (not paid House- keepers who receivo 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 bo 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 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, Ilomicide, 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.


Usal


COMMONWEALTH OF MASSACHUSETTS.


RETURN OF A DEATH-1911.


CITY OF BOSTON.


FULL NAME


Anna Williams


Registered No ....


8130


Place of Death ¿ Boston


Hillside Hospt.


and Residence


Date of Death


1911.


Age


years


months


6


days.


STATISTICAL DETAILS.


SEX


COLOR


SINGLE, MARRIED, WID., DIV.


F


1


S


Maiden Name ...


Husband's Name


Boston


Birthplace


Name of


Fred Williams


Father.


Bangor, Me.


Birthplace of Father


Anna Gibbins


Maiden Name


of Mother .. .


New York, N. Y.


T H Maguire


(Signed)


M.D.


Aug. 26 1911


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


Informant.


Place of Burial Mt.Hope


or removal.


Undertaker C E Colbert.& .Son


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


1911, from 1911, to 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:


ISTR PATRIBUS SIT DEL


AR'S


Multiple hemorrhages, nose,


CITY


Prima? (Duration) FICE


mouth, intestinal tracts -


CIYTTATIS


BOSTORIA' CONDITAA


BO.S SREGIMWE DONATA A 1130.


6 days


T


MASS.


Contributory : 3 Inanition - 6 days


(Duration)


Birthplace of Mother ..


Occupation


Usual Residence ..


Winthrop


Filed. Aug.29 1911


A true copy.


Attest : EMMYlenen


Registrar.


Aug. 26


.....


ug. 26, 1/1


6 DATE OF BIRTH 7 AGE 34 8 OCCUPATION (a) Trade, profession, or particular kind of work PARENTS important. See instructions on back of certificate. 16 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 (b) General nature of industry, business, or establishment in which employed (or employer)


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Winthrop (No. Detcall Hospital


Margaret Marie Walsh


'FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 6% Centre St Winthroh


PERSONAL AND STATISTICAL PARTICULARS


3 SEX Feriale White


4 COLOR OR RACE


5. SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Married


Fung


(Month)


6


1877


17


(Day)


(Year)


If LESS than I day, ..... . hrs.


or.


. min. ?


9 BIRTHPLACE


(State or country)


Boston Trass


10 NAME OF


Stellen Grady


11 BIRTHPLACE OF FATHER (State or country) Queland


12 MAIDEN NAME


OF MOTHER


Mary A Glancy


13 BIRTHPLACE


OF MOTHER


(State or country)


Bouton FRass,


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Robert W Walsh,


(Address)


6% QEntie St.


REGISTRAR


16 DATE OF DEATH


any


(Month)


28"


(Day)


191.).


( Year)


I HEREBY CERTIFY that I attended deceased from


J


, 191 ___


., to


amy 28'


.. , 1912 , that I last saw him alive on and 28" 1911. and that death occurred, on the date stated above, at /O fm . The CAUSE OF DEATH* was as follows : appendicitis ( Gangeneons.) alteration. Paralysis of Rispetory Centre


(Duration) ..


.yrs.


..


mos.


2 ds.


Contributory ..


(SECONDARY)


.(Duration),. . yrs.


mos. .


.ds.


.


(Signed)


31 Ducting


.. , M.D.


ans 29, 1911


(Address)


Washing.


* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.


16 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS). 6 horas In the


At place


of death.


yrs.


mos


ds.


State


... . . .. yrs. ....


mos.


ds ..


Where was disease contracted,


If not at place of death ?


(6) Contre St honderd st


usual residence


Former or


67 Contre St wowthat thing


19 PLACE OF BURIAL OR REMOVAL Holy Grows Centers


DATE OF BURIAL


Clica 3%, 1918


20 UNDERTAKER


holm + [ Dialer)


ADDRESS


19 (Atlantic. st.


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


Ward)


St. ;.. .


margaret In Trady wife of Robta Walsh


Registered No.


Filed .. - .... 191


MEDICAL CERTIFICATE OF DEATH


yrs.


2


mos.


22 s.


ds .


a


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 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 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 septicemia," " 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.


1


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 Inetcall Horhelal (No Whichwok St. ;... Ward)


BOSTON


(City or town.)


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


2 FULL NAME Francisca Bernice Murphy.


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


35 moore the


Single


26


18,93


(Year)


If LESS than I day, .... hrs.


Or ....... min. ?


Book Reader


11 BIRTHPLACE


OF FATHER


(State or country)


Putney Ut


12 MAIDEN NAME


OF MOTHER


Sarah. A. Conerty


18 BIRTHPLACE


OF MOTHER


(State or country)


albany Ut


"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Catherine, Jeans


(Address)


35 200000 ft


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Sept.


(Month)


(Day)


1911, (Year)


I HEREBY CERTIFY that I attended deceased from aug 29. , 1911 ..... to


Left 10h, 191. that I Gast saw her alive on the post of Sep., 191/ .. and that death occurred, on the date stated above, at 3Cm. The CAUSE OF DEATH* was as follows :


Intestinal Obstruction


(Duration)


.. yrs.


mos.


ds.


Contributory


(SECONDARY)


.(Duration)


yrs.


mos. ds.


(Signed)


Il. Porter


M.D.


Def. 2. 1911 (Address)


Nanthropo


*Af 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.


3 ds.


State /& .. .. yrs. ...


mos.


ds.


In the


.. ......


Where was d


If not at place of death ?.


dacris BCK. Hunshop


Former or


usual residence


35 marke St., Weatherop, mars


19 PLACE OF BURIAL OR REMOVAL


·


Lowell mars


DATE OF BURIAL


Left 4, 191


20 UNDERTAKER


CRBennemi


ADDRESS


Filed 191


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


white


female


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


(Month)


(Day)


7 AGE


18


5


ds.


yrs.


1


mos.


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


Williamin


PARENTS


WATTE PLAINGT, WITIT UNTADINO INK THIS IS A PERMANENT NEVUND.


9 BIRTHPLACE


(State or country)


Windsor Ut


17


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 he sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, 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 naturo 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 statemont. Never return "Laboror," "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: C'erebro-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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