USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 41
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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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