USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 6
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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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