Town of Winthrop : Record of Deaths 1910-1912, Part 59

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 59


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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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- mun, (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 Ilousc- 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, Hlousemaid, 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 discase ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless in- 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 septicacmia," " 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 onc 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 Winthrop Mass (No. 2.8 Oakland


Tancion


'FULL NAME Man


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


28 Oakland It Wantsa Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


m


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


m


6 DATE OF BIRTH


(Month)


(Day)


1


(Year)


7 AGE


68


. yrs.


Retired


8 OCCUPATION


(a) Trade, profession, or


particular kind of work.


(b) General nature of industry,


business, or establishment in


which employed ( or employer)


2 BIRTHPLACE


(State or country)


Canada


10 NAME OF


FATHER


Francis


PARENTS


12 MAIDEN NAME


OF MOTHER


Mary "Yall


13 BIRTHPLACE


OF MOTHER


(State or country)


Canada


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Daughter


(Address)


1) Winthrop nos Calvary


16


Filed.


191.


REGISTRAR


(Duration)


2 yrs.


...


mos.


ds.


Contributory


.(Duration)


yrs.


mos. .


.ds.


(Signed)


A.S. Dorman


.,


M.D.


Much. 18


.. 191 2. (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


March 1 8012


20 UNDERTAKER


ADDRESS


Barton


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


St. ;... .


Ward)


16 DATE OF DEATH


March


(Month)


(Day)


191.2


(Year)


17 I HEREBY CERTIFY that I attended deceased from Feb-11,, 1912, to. Aller, 16,. 1912


mos. .


ds.


If LESS than


1 day ........


hrs.


that I last saw how alive on


15, 192


or ...


min. ?


and that death occurred, on the dato stated above, at .. 605m.


The CAUSE OF DEATH* was as follows :


Heart Disease


Asthma (cardiac)


(SECONDARY)


Age


Broudutis


...


11 BIRTHPLACE


OF FATHER


(State or country)


Canada


Men . 10, 1114


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, Łoeo- 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., Careinoma, 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 deatlı), 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.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Wocheof .(No ... 4


St. ;


Ward)


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


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


noites


5 SINGLE,


MARRIED,


WIDOWED, I reducere-


OR DIVORCED


(Write the word)


1844


17


(Month)


(Day)


(Year)


7 AGE


67 yrs. mos. .. . ds.


or . min. ?


8 OCCUPATION (a) Trade, profession, or particular kind of work


at home


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


9 BIRTHPLACE (State or country) Welfare Quan


PARENTS


12 MAIDEN NAME


OF MOTHER


Betsey Corbett Perry


18 BIRTHPLACE


OF MOTHER


(State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


Filed ... 191 ..


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


TIT auch


(Month)


1%


(Day)


1912


(Year)


I HEREBY CERTIFY that I attended deceased from


March 7, 1912, to


Tauch 16, 1912,


If LESS than I day, .. .. hrs. that I last saw halive on. IT auch 16, 191.2. and that death occurred, on the date stated above, at. 1 0 Pm. The CAUSE OF DEATH* was as follows :


Central Huemontage


(Duration) . yrs. .. ....... mos .. 10 ds.


Contributory. (SECONDARY)


(Duration) yrs. .


mos. ... ds.


(Signed)


., M.D.


3/18/


1912 (Address).


263 Winthrop Se


* If death followed injury or violence the certificate of death must De 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 milford mais


DATE OF BURIAL


Mar 20. 1912


:0 UNDERTAKER


ADDRESS


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.


2 FULL NAME.


anna.


a. Lindsey


[ If married or divoreed woman or widow give maiden name, also name of husband.] @RESIDENCE Winthrop


Lunchsey - Hour


Registered No.


(City or town.)


6 DATE OF BIRTH


may


28


10 NAME OF


FATHER


Sco. 20. Hore


11 BIRTHPLACE OF FATHER (State or country) Matera Mais


much. 16, 1713


1


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the 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- mun, (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- kcepers 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 DEATHI, 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," " All- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ctc., 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 ....


53. Beac


St. :


Ward)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


male


+ COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


marsel


6 DATE OF BIRTH


afric


25


(Month)


(Day)


1841


(Year)


7 AGE


If LESS than day, . hrs.


70 yrs. .yrs.


10


mos. 23 ds.


or min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Retired


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


9 BIRTHPLACE


(State or country)


Eddington WILL


10 NAME OF


FATHER


Billings Cloth


PARENTS


11 BIRTHPLACE OF FATHER (State or country) Enquete me


12 MAIDEN NAME


OF MOTHER


Emily Whitney


13 BIRTHPLACE


OF MOTHER


(State or country)


Namara mas


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


ER Beno


(Address)


Filed .. 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Thank


(Month)


18


(Day)


1912


( Year)


17


I HEREBY CERTIFY that I attended deceased from


115 auch 8


191.2, to


III auch 18, 1912


that I last saw him alive on


TTauch 16, 1912,


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


6 f.m.


The CAUSE OF DEATH* was as follows :


General arterio delevaris


2 (Duration) .. yrs.


mos. . ds.


Contributory


(SECONDARY)


(Duration) .


yrs.


mos.


.... ds.


(Signed)


3/18/


191


263 Withau si-


* 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


S/12 1912


20 UNDERTAKER


ADDRESS Wuschel


M.D.


Charles. Setin Every Celofthe


2 FULL NAME


[If married or divoreed woman or widow give maiden name, also name of husband.] @RESIDENCE 53 Bear In


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, Loeo- 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 minc, etc. Women at home, who are engaged in the duties of the household only (not paid Hlouse- keepers who receive a definite salary), may be ontered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Caro 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 causc. 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 duc to Alcoholism, etc.


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


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(No .... 5-6 Park ave


St. ;


Ward)


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


Frances Mary Trowbridge


2 FULL NAME


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


Wedewof Geo. A. Wwwbudge


Seward


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


(Month)


(Day)


(Year)


7 AGE


70


yrs.


// mos. ..


6


ds.


or .... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


at home


If LESS than I day ... ..... hrs. that | last saw h. Er alive on .. 19 month 1912 and that death occurred, on the date stated above, at. O A m. The CAUSE OF DEATH* was as follows : Lober Pneumonia


.(Duration) ...


yrs. . . .


mos.


5-


ds.


Contributory


Valvular desean theart


(SECONDARY)


(Duration)


yrs. .


mos. .


ds.


Johnlo. Johnson


M.D.


(Signed)


Bank 209


1912


20 mrun St


(Address)


* If death followed injury or violence the certificate of death mastebe 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


Rear 22


1912


· UNDERTAKER


ADDRESS


Filed 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


March


205 7 191 2


(Month)


(Day)


( Year)


6 DATE OF BIRTH


14


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


11 BIRTHPLACE OF FATHER (State or country) England


12 MAIDEN NAME


OF MOTHER


Marchã ann Dexter


13 BIRTHPLACE


OF MOTHER


(State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


5.6 Park are winetent


N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state


1841


17


I HEREBY CERTIFY that I attended deceased from


march 15


1912


to


mand


1912


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


9 BIRTHPLACE


(State or country)


Chelsea mais


10 NAME OF


FATHER


Thomas A. Seward


(City or town.)


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engincer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm luborer, 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 110 occupation whatever, write None.




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