USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 62
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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, Gos 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
I PLACE OF DEATH
Sarah VHtwee-
2 FULL NAME
[ If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 3 Prospect avz.
Varney-Stephen W.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Undowad
6 DATE OF BIRTH
2 (Month)
(Day)
,
(Year)
7 AGE
If LESS than I day,. . . hrs.
75 yrs
mos.
10ds.
or ....... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
of house
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
10 NAME OF FATHER Samuel Wany
PARENTS
12 MAIDEN NAME OF MOTHER Place,
1ª BIRTHPLACE OF MOTHER (State or country) I H,
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed .. , 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
1912
(Year)
I HEREBY CERTIFY that I attended deceased from tan. 9th, 1912 April 5th, 192. that I last saw he alive on. .1912 and that death occurred, on the date stated above, at 4 P.m. The CAUSE OF DEATH* was as follows :
Diabetes
.(Duration) yrs.
Several
.. mos. ds
Contributory ..
(SECONDARY)
(Duration)
yrs.
mos. .
.ds.
(Signed)
Albert B. Douane
M.D.
..
af. 7
1912 (Address)
Withun Mask
* 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
11-8-1912
ADDRESS
10 UNDERTAKER
The. Skaggs
(City or town.)
(No. 3. Prospect QUE Ward)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
Age
11 BIRTHPLACE OF FATHER (State or country)
10
STANDARD CERTIFICATE OF DEATH. 1 1119
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 (uot 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, 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 : Meusles (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 cau 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, ete.
3. Sudden deaths of persous 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
YPLACE OF DEATH Winthrop (No ... 96 Forma (Kol)
St. ;....
Ward)
Winthrop (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
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Vingle
6 DATE OF BIRTH
May.
5
., 1852
17
(Year)
If LESS than 1 day, ....... hrs.
or ..
min. ?
(a) Trade, profession, or
particular kind of work
At Sterne
East Boston Inace
John Flaherty
Ireland
Frances LEE
Breton make
11 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Elizabeth trexl
Filed
., 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
April
(Month)
11
(Day)
1912
(Year)
I HEREBY CERTIFY that I attended deceased from
April 6
1912, to.
April 11, 19/1
that I last saw he alive on
April
11.1912
.. .
and that death occurred, on the date stated above, at ...
A.m.
The CAUSE OF DEATH* was as follows :
.. (Duration) ... yrs. mos. quote cantine Dilatation
5.
Contributory
(SECONDARY)
.(Duration) .
.yrs.
mos. ds.
Haven allally
.. M.D.
(Signed) April 1/1912 (Address)
325 25 int
* If death followed injury or violence the certificate of death must be made out Dy 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 a
DATE OF BURIAL
(1/22/ 13, 1912
DO UNDERTAKER
John file maker
ADDRESS
19 Atlantic St.
Pravduvel 3 SEX 4 COLOR OR RACE Female White (Month) (Day) 7 AGE 8 OCCUPATION (b) General nature of industry, business, or establishment in which employed (or employer) 9 BIRTHPLACE (State or country) 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (State or country) 12 MAIDEN NAME OF MOTHER PARENTS 13 BIRTHPLACE OF MOTHER (State or country) important. See instructions on back of certificate. (Address) 95 Jeving Rd . 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 59 .yrs. 11 mos. 6 ds.
laurel ( Amla Flaherty
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 975 Loving Rd
. 11, 1912
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 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 ('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) ; 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," " Dcbility" ("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 rosulting 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 violcnee, 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 4-12- 1912. (No. 210, Food Lide avz St.
(City or town.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Suple.
2
1804
(Year)
.. min. ?
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ...
theah HH, a. Macdonald
Filed 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
april
(Month)
(Day)
12, 92
(Year)
17 I HEREBY CERTIFY that I attended deceased from april 1910 ., to
april 121
191.2.
If LESS than I day ... hrs. that I last saw h walive on.
12 april 191.2. and that death occurred, on the date stated above, at 1 142m. The CAUSE OF DEATH* was as follows : Congenital Valvular hear disease Open foramen o vale
(Duration) 7 yrs. 4 mos. / O ds.
Contributory .. (SECONDARY)
(Duration) . yrs.
mos. .
.. ds.
(Signed)
ajul1 3"
191.2m (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
Сченлавстр.
20 UNDERTAKER
I.e. Shayan
DATE OF BURIAL
4/5.1912
ADDRESS
M.D.
10 NAME OF
FATHER
Hume a. Macdonald.
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 3 SEX 4 COLOR OR RACE W 6 DATE OF BIRTH (Month) (Day) 7 AGE 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) Boston 11 BIRTHPLACE OF FATHER 0 (State or country) Boston 12 MAIDEN NAME OF MOTHER PARENTS Theresa Porque. 13 BIRTHPLACE OF MOTHER (State or country) (Address) 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 7 yrs. 4 mos. 10 ds.
2 FULL NAME
Hurry J. macdonalds
apr. 12,141.
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 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, Ilousemaid, 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 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 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1912.
CITY OF BOSTON.
FULL NAME
LESLIE DIMOCK
Registered No .. 3815
Place of Death }
Boston
MASS. GENL.HOSPT.
and Residence S
Date of Death
APR. 14
1912.
Age
62
years
months days.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
F
WHITE
WID.
Maiden Name
BENNETT
STRAR
CARDIAC DILA. 24 DYS
Husband's Name
BEECHER S DIMOCK · PATRIBUS. AT Primary : (Duration) NOBIS SICUT.
CITY RI
OFFICE
Name of
DANIEL BENNETT
Father ..
18.31
BOSTONIMASS.
Contributory : 3
LOBAR PNEUMONIA - 10 DYS
(Duration)
Maiden Name
of Mother . MARY RAND
Birthplace of Mother.
Occupation
NONE
Informant
Place of Burial MT HOPE
or removal ..
Undertaker
J.S. WATERMAN & SONS
Usual Residence
WINTHROP
Filed
APR.18 1912
A true copy.
Attest
Registrar.
=
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
1912, from 1912, 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 :
Birthplace
PEREAU.N.S.
CJVYTATIS.
BOSTONIA TONDITRA
2 1822.
IS.REG
EGIMINE DUNATA D
Birthplace ENGLAND
of Father
(Signed) H. W. HERSEY M.D.
APR. 15 1912
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT. 7 DAYS
1
apr. 14, 1912
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
( No . 8 Pleasant St. .. .
Ruch ann Stores
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 8 Pleasant Ild
Widow of James. C. Store, Knapp.
Winchert Mas
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
6 DATE OF BIRTH
7 AGE
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
PARENTS
(Informant)
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
71
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
window
(Month)
(Day)
yrs.
mos.
10
ds.
or
min. ?
at home
(b) General nature of industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
Budgeton me
10 NAME OF
FATHER
George Knuth
11 BIRTHPLACE
OF FATHER
(State or country)
naples mme
12 MAIDEN NAME
OF MOTHER
Caroline Knuth
13 BIRTHPLACE
OF MOTHER
(State or country)
newbury park
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)
8 Pleasant Lin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
april
(Month)
15
, 1912
(Year)
(Day)
17 I HEREBY CERTIFY that I attended deceased from
Is april
If LESS than
1 day, ..
hrs.
that I last saw h M alive on
., 191.24
and that death occurred, on the date stated above, at.
1.45m.
The CAUSE OF DEATH* was as follows : General arterio Pelvisis Intral Insufficiency
(Duration)
2 yrs.
.. mos.
ds.
Contributory
(SECONDARY)
(Duration)
BIJduit call.
mos. .
ds.
, M.D.
(Signed)
936,91
. (Address)
Waithop
* 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
4/17
1912
10 UNDERTAKER
C.R. Benmoi.
ADDRESS
Filed .. 191
(City or towu.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
1840
(Year)
Jamay, 1910, to
april 15
, 191.2.
5-
apr. 15, 1912
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 minc, 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., 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.
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