Town of Winthrop : Record of Deaths 1910-1912, Part 9

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 9


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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.. years.


×


.months ...


days


W Mars


STATISTICAL DETAILS


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last illness, from .. June 30 19/0 Analy 22? to 19/0 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 :


apendicitis perforated


(DURATION). 24 DAYS


Contributory :


(DURATION ). .. DAY8


(Signed)


M.D.


Any 23


.19/0


(Address)


worthit has


SPECIAL INFORMATION only for Hospitais, Institutions, Translents, or Recent Residents.


How long at


20 dias


Piace of Death ?


months .. days


Where was disease contracted,


If not at place of death ?


Cust any hulp


Filed


.... 19


Cierk


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


FILL OUT WITH INK. - THIS IS A PERMANENT RECORD


ALL NAMES TO BE IN FULL


COLOR


SINGLE, MARRIED, WIDOWED, OR DIVORCED Lungen


MAIDEN NAME +


HUSBAND'S NAME t


BIRTHPLACE #


Philadelphia Pa


NAME OF


FATHER


Jacob Schiff


BIRTHPLACE


OF FATHER#


Germany


MAIDEN NAME OF MOTHER kenney Olschein


BIRTHPLACE


OF MOTHER +


Germany


OCCUPATION


at home


INFORMANT §


Siste


PLACE OF BURIAL OR REMOVAL li


Phil - Pa


DATE OF BURIAL


July 25


1960


UNDERTAKER


ADDRESS


Date of ¿ July 2 2 Death


19/ 0


years


SEX


Female


July 22, 1910


THE COMMONWEALTH OF MASSACHUSETTS


Winthrop .


(CITY OR TOWN.)


FULL NAME


auchan Thomas Selman Clay


Registered No .. ....


Date of l


7/24


19 /0


Death S


Death *


S


Residence


20 Collage an


40


9


months.


2 4.


days


457 WashingHowIt Newtow Mass.


STATISTICAL DETAILS


SEX


Male


COLOR


White


SINGLE, MARRIED, WIDOWED, OR DIVORCED


Manuel


MAIDEN NAME Ť


HUSBAND'S NAME Ť


BIRTHPLACE # Nalafax U.S.


NAME OF


FATHER


Thomas Clay


BIRTHPLACE


OF FATHER#


England


MAIDEN NAME


OF MOTHER


Christyann Dunn


BIRTHPLACE


OF MOTHER #


England


OCCUPATION


Salesman


INFORMANT § wife


Filed


19


Clerk


PLACE OF BURIAL OR REMOVAL !!


DATE OF BURIAL


7/26


19/0


UNDERTAKER


ADDRESS


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that i attended deceased during last illness, from Lecker 0 1010 to fully 2x 1910 . that to the best of moy knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary :


Contributory :


amentos


(DURATION).


. DAYS


(Signed)


M.D.


Recla 25 19/0 (Address) Nanetropp


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


How long at


Place of Death ?


. years.


months. days


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


* 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


RETURN OF A DEATH


Place of l


20 Collage are winthrop


4 Age


.years.


(DURATION) ISCR DAYS


arthur 1. S. way July 24, 1910


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.


PARENTS


12 MAIDEN NAME


OF MOTHER


Honora. haner


13 BIRTHPLACE


OF MOTHER


(State or country)


Tienes n. 4,


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


159 Diewelt &Ha.,


16


Filed .. 191


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month)


(Day)


19!


(Year)


1850 17 | HEREBY CERTIFY that I attended deceased from


191


to.


191.


If LESS than


I day, ..


„hrs.


that | last saw h


alive on


, 191


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


m.


The CAUSE OF DEATH* was as follows :


(Duration).


yrs. .


mos. ...


ds.


Contributory


(SECONDARY)


(Duration)


yrs.


mos. ..


ds.


(Signed)


M.D.


.,


191


(Address).


* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).


At place


of death


yrs.


mos.


ds.


State.


yrs. ..


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


Clay 2. 1910


20 UNDERTAKER


ADDRESS


REGISTRAR


1


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Worcester Mars ( No .


July 30 1910


St. ;


Ward)


BOSTON (City or town.)


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


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


male


4 COLOR OR RACE


(Month)


(Day)


-


(Year)


7 AGE


54 yrs. mos. 29 ds.


or min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Mannen


Barton Theus


(b) General nature of industry,


business, or establishment in


which employed (or employer)


3 R.R.T.L.R.R.


9 BIRTHPLACE


(State or country)


10 NAME OF


FATHER


Thomas Scott


11 BIRTHPLACE


OF FATHER


(State or country)


George. Wales Scott


2 FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 46 Seynne St Winchrote H1020


Registered No.


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


20


3


The Commonwealth of Massachusetts


In the


-- XNI DNIOVANA


I V SI SIH.L - A PERMANENT RECORD


C


C July 30, 1910


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 linc is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salcs- man, (b) Grocery ; (a) Forcman, (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- Coul 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 fevcr (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 state 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 " ("('ongenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc. when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL, peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as .A death upon the street, or one supposed to be due to Alcoholism, etc.


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


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Worcester.


(No .. State Hospital


St. :


Ward)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Male


4 COLOR OR RACE


W


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Married


6 DATE OF BIRTH


1856


1


(Month)


(Day)


(Year)


7 AGE


54


-


yrs.


mos.


ds.


Or ......... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Steamboat captain


Palot.


(b) General nature of industry.


business, or establishment in


which employed .(or employer):


9 BIRTHPLACE


(State or country)


Boothbay, Me.


10 NAME OF FATHER Thomas


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Nova Scotia


12 MAIDEN NAME


OF MOTHER


Hanora McNeil


12 BIRTHPLACE


OF MOTHER


(State or country)


Nova Scotia


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


Ray L Whitney


(Informant)


Worcester.


(Address).


Filed


191


REGISTRAR


MEDICAL: CERTIFICATE OF DEATH:


14 DATE OF DEATH


July ..... 29,


191.0


(Month)


(Day)


(Year)


17


I HEREBY CERTIFY that I attended deceased from


Nov 2,


1908


July 29,


0


to


191


im


July 29,


199


and that death occurred, on the date stated above,


11 Pm.


The CAUSE OF DEATH* was as follows :


General piralysis of the insane


3


(Duration)


. . yrs.


mos.


ds.


Contributory.


Exhaustion of general paral-


(SECONDASiS.


1


(Duration)


yrs.


mos.


ds.


R L


Whitney


M.D.


Jul 30.


0


2, 191


(Address)


Worcester.


* 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.


28


In the Unknown


ds.


State ........


.. yrs.


mos.


. ds ...


Where was disease contracted,


TInknown


If not at place of death ?.


Former or Winthrop.


usual residence.


19 PLACE OF BURIAL OR REMOVAL


Boston


DATE OF BURIAL


Aug 2,


0


191


AUX


20 UNDERTAKERS A Putnam


ADDRESS Cester.


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


(City or town.)


George W Scott


2 FULL NAME


[If married or divorced woman or widow


give maiden namo, also name of husband;]


@RESIDENCE


Winthrop.


If LESS than


I day, ....


. hrs.


that i: last saw h


alive on


(Signed)


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, Housemaid, etc. If the occupation lias 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. - Nanie, 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.


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.


ALL NAMES TO BE IN FULL


THE COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH


(CITY OR TOWN.)


FULL NAME


backermin . Phothe blouson


Registered No.


67


Place of ¿


Death *


5


390 Whichnow It Waiting


Residence


West Roxbury Man


Age 64


... years.


X


months -8 days


STATISTICAL DETAILS


SEX


temale


COLOR


White


SINGLE, MARRIED, WIDOWED, OR DIVORCED


MAIDEN NAME +


Jackson


HUSBAND'S NAME +


Ww a. Johnson


BIRTHPLACE #


Charlestown man


NAME OF


FATHER


Swo Perkins Jackson


BIRTHPLACE


OF FATHER $


MAIDEN NAME


OF MOTHER


E actuina Bran


BIRTHPLACE


OF MOTHER $


Barcon- mais


OCCUPATION


at-1 tours


INFORMANT §


Aero Mary E Mumor


390 Marchioh &m;


PLACE OF BURIAL OR REMOVAL II


Woodlawn Comelig Insect


DATE OF BURIAL


7/19


.. 19/ G


UNDERTAKER


BR Berman


ADDRESS


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last illness, from ... July 16. 9


to


vody/26 19 CV,


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 :


Intenstitul


Nephutis


(DURATION).


DAYS


Contributory :


Carcinoma


(DURATION)


. DAYS


(Signed)


M.D.


July 2] 19:1


(Address)


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


How long at


Place of Death ?


. years ..


................


. months.


...... days


Where was disease contracted,


If not at place of death ?.


Filed


19


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 marrled 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.


Date of ¿


7/26


1910


Death 1


July 26, 1910


THE COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH


(CITY OR TOWN.)


FULL NAME


annie Delves ambler


.Registered No.


68


Place of }


409 Shirley St Wuchart


Date of ¿


1/27


Death S


19/0


Death *


.


Residence


STATISTICAL DETAILS


SEX Female


COLOR


SINGLE, MARRIED, WIDOWED, OR DIVORCED


manuel


MAIDEN NAME $


Delves"annie"


HUSBAND'S NAME t


alfred. It. ambler


BIRTHPLACE #


England


NAME OF


FATHER


Samuel Delvis


BIRTHPLACE


OF FATHER#


England


MAIDEN NAME


OF MOTHER


Mariann Thorley


BIRTHPLACE


OF MOTHER #


England


OCCUPATION


A Home


INFORMANT §


Sanghte & Husband


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last illness, from ... Janey 26 1910 to. July 27 1910. 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 :


Chronic Brughto Diverse


several years.


.(DURATION)


........ DAYS


Contributory :


aceites


uncertaino


(DURATION).


DAYS


(Signed)


M.D.


July 2719/0 (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


19


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


PLACE OF BURIAL OR REMOVAL II


Marchiof Semely


DATE OF BURIAL


7/29


19/0


UNDERTAKER


6 R Benmen


ADDRESS


Wucher


man


Age.


47


.years.


.months.


10


.days


July 27, 1910.


THE COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH


(CITY OR TOWN.)


FULL NAME


Hamah Elizabeth Ilestora


Registered No.


69


Place of


Death *


5


Residence


1


11


11


Ag


11 years


.... . months.


U .. days


STATISTICAL DETAILS


SEX


COLOR


SINGLE, MARRIED, WIDOWED, OR- DIVORCED


Hawkins


MAIDEN NAME T


HUSBAND'S NAME t Harfleurw Huston


BIRTHPLACE #


NAME OF FATHER


BIRTHPLACE


OF FATHER#


SommerCitabine Conglands


MAIDEN NAME


OF MOTHER


BIRTHPLACE OF MOTHER # England


OCCUPATION


INFORMANT §


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last illness, from Quale 25 .19 to. July 29 19/0 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 : Enteritis,


(DURATION).


DAYS


Contributory :


(DURATION). .......... DAYS


(Signed)


M.D.


July 27 1900


(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


.19


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. || Name of cemetery.


ALL NAMES TO BE IN FULL


PLACE OF BURIAL OR REMOVAL I!


DATE OF BURIAL July 3/ 19/0.


UNDERTAKER If. C. Skangu


ADDRESS Columbia 17


Date of ¿


.19/0,


Death 1


IT ---------


July 29, 1910


PARENTS 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. 16 N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state -


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Hinitrop Mar. (No. 290 Bowdoin


St. ;.


Ward)


'FULL NAME 0 Hice Whaley roble


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


Oscar Yo.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


widow


6 DATE OF BIRTH


Jan.


(Month)


(Day)


1828


(Year)


7 AGE


If LESS than 1 day ..... . . hrs ..


yrs. 7 mos. / ds. or ....... min. ?


8 OCCUPATION


(a)' Trade, profession, or


particular kind of work


to home.


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


9 BIRTHPLACE


(State or country)


try) Pourich Conn


Conn.


10 NAME OF


FATHER


Fr haben.


11 BIRTHPLACE OF FATHER (State or country)


12 MAIDEN NAME OF MOTHER unnie (madon


13 BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


-


(Informant)


Lowin Noble


(Address)


Hansturk


Filed 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


aug.


1910


(Month)


(Day)


(Year)


17


I HEREBY CERTIFY that I attended deceased from


Suela 25


1910, to.


Cinq 3, 1910,


that I Mast saw h


Me alive on


... 191. 0,


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


. . m.


The CAUSE OF DEATH* was as follows :


Entero colitis


(Duration)


.yrs.


mos.


.ds.


Contributory


Oca aqu


(SECONDARY)


(Duration)


yrs.


mos. . . .. ds.


(Signed)


Trx. Parce)


M.D.


Tranche of hoar


1910 (Address)


* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).


At place


of death


yrs.


mos. . .


ds.


State


yrs.


In the


mos. .


ds.


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


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


1910


20 UNDERTAKER


ADDRESS


brown


BOSTON


(City or town.)


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


Registered No. 70


82


0


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 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 "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-




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