Town of Winthrop : Record of Deaths 1910-1912, Part 62

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 62


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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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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