Town of Winthrop : Record of Deaths 1910-1912, Part 6

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 6


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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5/10


19 ( G


UNDERTAKER


ADDRESS .


* 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 detalls. Il Name of cemetery.


Mas


Date of l


5/8


19/0


Death S


Phil That fievina


25 tomat 51


46 William a. aiken May 8, 1910


THE COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH Sennett Duffy aubrey


(CITY OR TOWN.)


FULL NAME


Place of


64 Narla Vieio Dvc


Death *


S


Residence


Wacht Man


Age


years.


10


20


months


days


STATISTICAL DETAILS


SEX


COLOR


Meto


SINGLE, MARRIED, WIDOWED, OR DIVORCED


MAIDEN NAME +


HUSBAND'S NAME t


BIRTHPLACE + 64 Harbour View are


NAME OF FATHER Bengemain .a .


BIRTHPLACE OF FATHER $ New Haven Com


MAIDEN NAME OF MOTHER Ruby Rose Beam


BIRTHPLACE OF MOTHER $ New Haven Com


OCCUPATION


INFORMANT §


PLACE OF BURIAL OR REMOVAL II


DATE OF BURIAL May 18


1000


UNDERTAKER


ADDRESS


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last iliness, from apon. 1 .19/0 to o May 16 /9/0, 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 :


Infantile Paralyzer


(DURATION). DAYS


Contributory :


(DURATION). .... .. DAYS


(Signed)


M.D.


May 18/19/10 (Address)


SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.


How long at


Place of Death ?


.years.


...... ..... . months. days


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


Filed


1910.


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 detalls. Il Name of cemetery.


ALL NAMES TO BE IN FULL


Registered No ..


47


Date of l


May 165


19/0


Death 1


47 Bennett Duffy. aubrey May 16 , 1910 ,


-


THE COMMONWEALTH OF MASSACHUSETTS


Winthrop


RETURN OF A DEATH


(CITY OR TOWN.)


FULL NAME


Robert Hawthorne Hanley


Registered No.


4 8


Place of metall/fordulat Wucherof news


Death *


Residence


Age


14


6


years.


.months.


STATISTICAL DETAILS


SEX


Mal


COLOR


White


SINGLE, MARRIED. WIDOWED, OR DIVORCED


Linga


MAIDEN NAME +


HUSBAND'S NAME t


BIRTHPLACE # function mais


NAME OF FATHER William H. Hanly


BIRTHPLACE


OF FATHER$


Phil - Pa


MAIDEN NAME OF MOTHER Maggie Mc Lane


BIRTHPLACE OF MOTHER + Pavelane


OCCUPATION


School Boy


INFORMANT §


Parents


PLACE OF BURIAL OR REMOVAL I


DATE OF BURIAL May 201010


UNDERTAKER


ADDRESS Wincent


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last iliness, from .. May 15 19/0 to my 18 1918, 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 : Perforated appendix


General Peritonitis


.. (DURATION).


3


DAYS


Contributory :


(DURATION). ..... .. DAY8


(Signed)


M.D.


(9 191) (Address)


SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.


How long at


months.


Place of Death ?


years.


3


days


Where was disease contracted,


if not at place of death ?


Filed


19 / 0.


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. Il Name of cemetery.


FILL OUT WITH INK. - THIS IS A PERMANENT RECORD


ALL NAMES TO BE IN FULL


Date of ¿


May 18th


19/ 0


Death )


7 days


48 Robert Hawthorne Hanly May 18, 1910 .


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


I PLACE OF DEATH


(No.)9 Atlantic St .; Ward)


Ellen Theresa ( Maler


2 FULL NAME


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


Ellen Therese Kelly- John F. 6 maly.


Registered No.


+9


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


female


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


married


6 DATE OF BIRTH


(Month)


(Day) (Year)


7 AGE


34


... yrs. 4 mos. 16


ds.


or ........ min .?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Housewife


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


9 BIRTHPLACE


(State or country)


East Boston mass.


10 NAME OF


FATHER


Patrick Kelly.


11 BIRTHPLACE


OF FATHER


(State or country)


Ireland


12 MAIDEN NAME


OF MOTHER


Bridget Kahve


13 BIRTHPLACE


OF MOTHER


(State or country)


Ireland


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


John 7: 00 maler


(Address)


29 Atlantic It


15 Filed June 4, 191 2.


REGISTRAR


.


(Month)


(Day)


(Year)


17 I HEREBY CERTIFY, That I attended deceased from Or may 22 1910 ..... to 191


that I last saw her


alive on


may 21


1910


and that death occured, on the date stated above, at. ......... m. The CAUSE OF DEATH* was as follows :


Acute indigestion


(Duration) .yrs. . mos. ds.


Contributory


Pulmonary tuberculosis


(SECONDARY)


(Duration)


3


.yrs.


mos.


ds.


(Signed)


Edward J. Franger


M. D.


May 22, 191.0 (Address)


304 Wwilling Sr.


* 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 placa of death ?


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL Holy Cross malden


DATE OF BURIAL


May 24h


1910


20 UNDERTAKER


ADDRESS


Fuck A. magrath 60 meridian &t &


WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.


STANDARD CERTIFICATE OF DEATH


Winthrop


BOSTON


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


16 DATE OF DEATH


Way


21


1910


1


If LESS than


I day, ........ hrs.


1


?


Standard Certificate of Death.


Ellen Theresa OMaley May 21, 1910


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, Locomotive engincer, Civil engineer, Stationary o fircman, 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, cand 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) Salesman, b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," ".Dealer," etc., without more precise specification, as Day laborcr, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Houscwork, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report specifically the oceupations of persons engaged in domestic service for wages, as Scrvant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at begin- ning 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: Ccrebro-spinal fevcr (the only definite synonym is " Epidemic cerebro-spinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia "); Lobar pneumonia;


Broncho-pncumonia (" Pneumonia," unqualified, is indefi- nite); Tuberculosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sarcoma, 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 (secondary or intercurrent) affection need not be stated unless important. Example: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (second- ary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," "Anaemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Con- vulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemor- rhage," "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 "PUERPERAL 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 fol- lowing conditions must be referred to the Medical Exanı- incrs :


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, Exposure, 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


RETURN OF A DEATH alexander


(CITY OR TOWN.)


FULL NAME


Place of l


Death * S


Residence


5 Summit are


Age


..... years ..


.months ...


days


STATISTICAL DETAILS


SEX


m


COLOR


SINGLE, MARRIED, WIDOWED, OR DIVORCED


MAIDEN NAME Ť


HUSBAND'S NAME t


BIRTHPLACE#


1


١٤


NAME OF


FATHER


BIRTHPLACE OF FATHER$ Frames Tom Ac Hb


MAIDEN NAME


OF MOTHER


Georgia L. Word.


BIRTHPLACE OF MOTHER $ Nashua V. Manşehir


OCCUPATION


INFORMANT §


Harrey I. activities


PLACE OF BURIAL OR REMOVAL II


DATE OF BURIAL July 8# Winter Connely To


UNDERTAKER


ADDRESS


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last illness, from .19


to ............ 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 : Stillhorn


(DURATION)


DAYS


Contributory :


(DURATION) . DAYS


(Signed).


M.D.


Dleges 35 19/0 (Address).


SPECIAL INFORMATION only for Hospitals, institutions, Transients, or Recent Residents.


How long at Piace of Death ? . years. ......... ........ . months. . days


Where was disease contracted,


if not at place of death ?


Filed


aug.


6,1910


Eulalie Churchill


asit. Towy 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. Il Name of cemetery.


ALL NAMES TO BE IN FULL


Registered No.


58


Date of l


may 23


19 40


58 51 alexander May 23, 1910.


Z


alexander


3 SEX female 7 AGE 8 OCCUPATION (a) Trade, profession, or particular kind of work 11 BIRTHPLACE OF FATHER (State or country) PARENTS 13 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 (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 ... 50. Atlantic St. ;..


(City or town.)


Ward)


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


Emily Shaw Henderson 2 FULL NAME.


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


maiden name Thing window of John D. Hunden


Registered No. 50


PERSONAL AND STATISTICAL PARTICULARS


4 COLOR OR RACE


white


5 SINGLE,


MARRIED,


evidowed


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH March 23


(Month) (Day)


62 yrs. 2 mos. 3


ds.


or min. ?


At home


9 BIRTHPLACE


(State or country)


London England


10 NAME OF


FATHER


George Thing


England


12 MAIDEN NAME OF MOTHER Sophia


England


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant).


Jessie 6. Henderson


(Address) 50 Atlantic St. Hinrich.


15 Filed June H. 191.0.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH may (Month)


26 (Day)


, 1910. (Year)


I HEREBY CERTIFY that I attended deceased from


May


26


1910


to .


may 26


, 1910


If LESS than


1 day, ...


hrs.


that I last saw h alive on


may 26


, 191º ,


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


8: 49 m.


The CAUSE OF DEATH* was as follows :


muelilacula cyst


and


mamma


at .


yrs.


mos. .


ds.


Contributory


(SECONDARY)


( Duration)(


yrs. .


mos.


M.D.


May 27, 190


(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


Glenwood Everett May 28, 1910


20 UNDERTAKER.S


ADDRESS


I. E. Henderson & bio Everett Masz


, 1848 17


(Year)


mamma


(Signed)


STANDARD CERTIFICATE OF DEATH.


26,1910


0


10


Emily S. Henderson


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, irrespectivo 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 tho DISEASE CAUSING DEATH, stato 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 ('AUSING 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) ; Meusles ; 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 duc to Alcoholism, etc.


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


THE COMMONWEALTH OF MASSACHUSETTS


Winthrop (CITY OR TOWN.Y


RETURN OF A DEATH


FULL NAME Bettie E. Jury


......


Place of )


Death *


Residence


11


1


1


Age 5-0 years


2 months .____ days


STATISTICAL DETAILS


SEX


COLOR


w-


SINGLE, MARRIED, WIDOWED, OR DIVORCED


MAIDEN NAME +


Mettre E. Vaughan


HUSBAND'S NAME Ť Carney S. Jury.


BIRTHPLACE$ Redford 92-4.


NAME OF


FATHER


Rodiny Vaughan


BIRTHPLACE OF FATHER$ Redford 9.1.


MAIDEN NAME


OF MOTHER


Ellen Parsons.


BIRTHPLACE


OF MOTHER $


Dannemora n.y.


OCCUPATION at home


INFORMANT § Unknown


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last iliness, from Munch 19\V to.


Musel 26101U. 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 : angieTexturis


(DURATION). DAYS


Contributory : Queria Intentitil


Nephritis Harentu ell


(DURATION) DAYS


(Signed)


M.D.


5 26 19 \V (Address)


263


SPECIAL INFORMATION only for Hospitals, institutions, Transients, or Recent Residents.


How long at Place of Death ? . years.


......


months. ................ days


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


Filed 0 4 1910. Priston BChurchill.


Clerk


PLACE OF BURIAL OR REMOVAL !


Permecook 7.H.


DATE OF BURIAL


5=29


19/0.


UNDERTAKER IV. C. Skaggs


ADDRESS Columbia Sy


* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Speclal 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. Il Name of cemetery.


ANOSEN INANYWNEJ Y SI SIHI-WNI HIIM 100 7713


ALL NAMES TO BE IN FULL


.Registered No. 51


Date of ! May 26 .19/0.


Death S


51 nettie E. Terry May 26 , 1910


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 PARENTS


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Hospital, Fort Banks, Mass.


St. ;. Ward)


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


'FULL NAME


Thomas Foley, Pvt. 1,el., Hospital Corps, M. F.


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


Single.


@RESIDENCE


Registered No.


52


PERSONAL AND STATISTICAL PARTICULARS


3 SEX Male


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)"


Single


6 DATE OF BIRTH


Unkrom


(Month)


(Day)


(Year)


7 AGE


36


yrs.


mos.


ds.


or ....... min. ?


8 OCCUPATION


(a)' Trade, profession, or


particular kind of work


Collier.


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


9 BIRTHPLACE


(State or country)


JaSS.


10 NAME OF


FATHER


Urkr.owr ..


11 BIRTHPLACE OF FATHER (State or country)


12 MAIDEN NAME OF MOTHER


Urkrowr.


13 BIRTHPLACE


OF MOTHER


(State or country)


Unknown.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


mydamen Ceret .. . ".


(Address)


Hospital, Ft. Paris


Tags.


16 Filed June 4 1910.


Preston BChurchill REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


17


I HEREBY CERTIFY that I attended deceased from


Hay Kiss


. 1910


., to


Hay 29th


.. , 1910 ,


that | last saw ht'l


alive on


Tay 29th


1910


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


The CAUSE OF DEATH* was as follows :


Uncomia


(Duration)


.yrs. .. mos.


ds.


Contributofy ..


(SECONDARY)


que certero selervar Chronic inte.


aortic Insufficira, double tytothorax


(Duration)


yrs.


mos. . .ds.


(Signed)


atumero


Major, C. C. M.D.


Hoy 29-11191.2. (Address).


Fort Barks, Mess.


* 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.


8


ds.


In the


State


0


yrs.


8


mos. .


ds.


Where was disease contracted,


If not at place of death ?.


Unknown


Former or


usual residence.


1 PLACE OF BURIAL OR REMOVAL Maynard mars.


DATE OF BURIAL


191


20 UNDERTAKER


ADDRESS


280 meridian St


Gordon D. W. Brown East Boston


29th , 1910.


(Month)


(Day)


(Year)


If LESS than


1 day, ... hrs.


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 quostion 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 enginecr, 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 sccond statement. Nover return " Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborcr - 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 " Cronp") ; 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.




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