Town of Winthrop : Record of Deaths 1913-1915, Part 116

Author: Winthrop (Mass.)
Publication date: 1913
Publisher:
Number of Pages: 1094


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 116


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COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1915.


ANNIE F. KITCHELL


FULL NAME


Place of Death ) and Residence S


Boston


MASS. HOMOEO.HOSPT.


1915. Age 62


years


I


months


16


days.


STATISTICAL DETAILS.


PHYSICIAN'S CERTIFICATE.


SEX.


COLOR.


SINGLE, MARRIED, WID., DIV.


F


MAR


Maiden Name


FORTER


EGIST


. SIT DE


Primary ( Duration1


FFICE


15 YRS


Birthplace


ENGLAND


Name of Father


FRANK FORTER


Birthplace of Father


ENGLAND


Maiden Name of Mother


-


Birthplace of Mother


ENGLAND


(Signed)


E. D. LEE M.D.


1915


SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recen! Residents.


Place of Burial or removal


WINTHROP ( WINTHROP CEM)


WINTHROP( 22 REED ST)


Undertaker


W. C. SKAGGS


Filed


NOV.26 1915


WINTHROP


A true copy. Attest : Ermslenen


Registrar.


O


I HEREBY CERTIFY that I attended deceased during last illness,


from


1915, to


1915, 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 : RAR'S


Husband's Name


GEORGE W. KITCHELL


PATRIC


CHR. VALV.HEART DISEASE -


CTV BOSTONIA


TA A 1822.


OSTO CONDITAA TIS REGIMINE DONATA A N. MASS


( OPR . NOV. 20. 1915)


Contributory · (Duration)


Occupation


Informant


Registered No.


Date of Death


NOV . 21


CITY OF BOSTON. 10463


Usual Residence


YILou. 21, 1915


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


(No.


40 Cross


St. ;...


Ward)


annie Elisa Mac Hadden


2 FULL NAME


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


wie af Solen


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


november 23


(Month)


(Day)


19


1915


(Year)


17


I HEREBY CERTIFY that I attended deceased from


n.v. 1


1915, to


Uns 23. 195


that I last saw her alive on


mv. 21


1910


and that death occurred, on the date stated above, at 8:48 AM


The CAUSE OF DEATH* was as follows :


Igranditos


Chris Interstitial hethit


... yrs. ............. ... mos. ........ ds. .(Duration)


Contributory (SECONDARY)


.(Duration). ... yrs. ............ ... mos. ............ ds.


(Signed)


CF mahoney


M.D.


IN. 24, 1915 (Addres 55 weinflemoto So


* 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


In the


of desth.


.......


... yrs.


.. mos.


ds.


State ............ y ... ............ mos. ............ ds __.........


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


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL


" UNDERTAKER


e. R. Pensum


DATE OF BURIAL Serv 26 S


191


ADDRESS


191


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


1835


(Year)


7 AGE


If LESS than


[ day ........ hrs.


or ....


min. ?


$ OCCUPATION


(a) Trade, profession, or


particular kind of work


at Home


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


9 BIRTHPLACE


(State or country)


Jedney Cafe Brica-


PARENTS


12 MAIDEN NAME


OF MOTHER


Eleanor Pitt


1ª BIRTHPLACE OF MOTHER (State or country


"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


e. R. Nemum


(Address)


16


Filed


REGISTRAR


(City or town.)


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


3 SEX


4 COLOR OR RACE


DATE OF BIRTH Jul 16 (Month) (Day)


79


............... yrs.


3


mos.


10 ds.


10 NAME OF


FATHER


- Frederick Lewis


11 BIRTHPLACE


OF FATHER


(State or country)


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occu- pation 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 sehoo' 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 occu- pation whatever, write None.


Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to tiine and causation), using always the same accepted term for the same diseasc. Examples: Cerebro-spinal fcver (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-


eulosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. „(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); 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 .; Broneho-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 discases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


1


Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing 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, ctc.


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. .


-


,


1


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


1 PLACE OF DEATH Whittrop - Shoot Beach (Ocean)


St. .Ward)


2 FULL NAME ..


William H. Hitchens


[If married or divoreed woman or widow


give maiden name, also name of husband.]


@RESIDENCE


18 Madison St., Somerville, 2 Winthings


Registered No.


11581


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


male


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCEL


(Write the word)


6 DATE OF BIRTH


(Month)


(Day)


1


(Year)


7 AGE


If LESS than


1 day, ........ hrs.


62 yrs. mos.


ds.


or ......


min. ?


& OCCUPATION


(a) Trade, profession, or


particular kind of work


Talisman Real Estate


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


9 BIRTHPLACE


(State or country)


Barrington U.S.


10 NAME OF


FATHER


William Matchens


PARENTS


11 BIRTHPLACE OF FATHER (State or country) Barryton n.f.


12 MAIDEN NAME


OF MOTHER


margeret Harryten


13 BIRTHPLACE OF MOTHER (State or country) Barryton n.S.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Mennie Niteferro


(Address)


Filed ... ., 191


REGISTRAR


16 DATE OF DEATH


(Month)


(Dayh)


(Year)


17 I HEREBY CERTIFY that I have investigated the death of the deceased.


The CAUSE OF DEATH* was as follows : Drowning, accidental


( Presumable Syncope while


batting in the ocean due to Sclerosis with Stenosis of the left cronoany Consterumbs. ds. Contributory (SECONDARY)


(Duration)


yrs.


.mos.


ds.


(Signed) Cung


Lung Burgen Magrath


M.D.


Mr. 29. 81


5


(Address)


12.55 P.M MEDICAL EXAMINER


* State the DISEASE CAUSING DEATII, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.


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


At placo


of death.


... yrs.


.. mos.


ds.


State.


......


In the


... yrs.


mos.


ds ............


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


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL


Woodlawn


went


DATE OF BURIAL


Dec 1. 195


DO UNDERTAKER


gas. a Lovely


ADDRESS


429 Broadway


7363 Wulterap (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]


MEDICAL CERTIFICATE OF DEATH


27


1915


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occu- pation 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, ete. But in many eases, 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) Salcs- man, (b) Groecry; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm laborer, Laborcr - Coal minc, ete. Women at home, who are engaged in the duties of the household only (not paid House- kecpers 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 domestie 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 faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.


Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Ccrebro-spinal fcvcr (the only definite synonym is "Epidemic eerebro-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, peritonacum, etc., Carcinoma, Sar eoma, etc., of .. ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasins) ; Mcasles; Whooping cough; Chronie valvular heart discasc; Chronic interstitial nephritis, etc. The contributory (second- ary or intereurrent) affection nced not be stated unless im- portant. Example: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acinia" (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 ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State


eause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI-


DENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homieidc; Poisoned by carbolie acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., scpsis tetanus) may be stated under the head of "Contributory."


Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.


2. Deaths supposedly eaused by violenee, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ete.


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


4. Deaths under eireumstances unknown, as A person found dead, ete.


important. See instructions on back of certificate. CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 1. D.


The Commmwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


PLACE OF DEATH


Winthrop


(No.


383 Pharauf


St.


...... Ward)


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


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


¿ SEX


In


{ COLOR OR RACE


W


5 SINGLE,


MARRIED Mare


WIDOWED,


(Write the word)


$ DATE OF BIRTH


6


13-


.. 1867


(Year)


(Month)


(Day)


7 AGE


If LESS than


1 day ......... hrs.


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


$ OCCUPATION


(a) Trade, profession, or


particular kind of work


Electricians


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


9 BIRTHPLACE


(State or country)


The


Thompkinsville et.


10 NAME OF


FATHER


George Stevens.


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Scotland


12 MAIDEN NAME


OF MOTHER


Many Black.


18 BIRTHPLACE


OF MOTHER


(State or country)


Scotland


"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address) 383 PleasantSturen


16


Filed 191


REGISTRAR


17


I HEREBY CERTIFY that I attended deceased from


29


1915, to


Los 29


191_5,


that I last saw h~ alive on


1915


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


2'5 P.m.


The CAUSE OF DEATH* was as follows :


arturo


3 /2 hours .


(Duration)


yrs.


ds.


mos.


artico - actuais.


Contributory ...


(SECONDARY)


.. (Duration) ..... yrs.


mos.


ds.


(Signed)


R. B. Parken


M.D.


1


1915 (Address)


D


.


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


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


In the


At place


of death


.......... yrs.


.......... mos.


ds.


State ............ yrs. ............ mos.


Where was disease contracted, If not at place of death ?. Former or usual residence


" PLACE OF BURIAL OR REMOVAL Felicito Cequeley


DATE OF BURIAL


Lyng0 01 + 22 212-2- 1915-


D UNDERTAKER


ADDRESS


Wirellesof ..


...


George R.Stevens


2 FULL NAME


[If married or divorced womanor widow


give maiden name, also name of husband.]


@RESIDENCE


Northrop, 383 Pleasant


.... Registered No.


16 DATE OF DEATH


2000


(Month)


29.


.... 191.5


(Dáy)


(Year)


48 yrs. 5 mos. 16 ds.


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occu- pation 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, Architeet, Loco- motive engineer, Civil engincer, Stationary fireman, ctc. 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) 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 - 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 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 occu- pation whatever, write None.


Statement of cause of death. - Name, first, the DIS- EASE 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, peritonacum, 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 necd not be stated unless im- portant. Example: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (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 septieacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing 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 onc 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


1 PLACE OF DEATH


(No. . ...


St. : .......... Ward)


(City or town.)


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


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


4 COLOR OR RACE


6 SINGLE,


MARRIED.


WIDOWED,


OR DIVORCED


(Write the word)


1


· DATE OF BIRTH


(Month)


(Day)


(Year)


7 AGE


If LESS than


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


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


· OCCUPATION (a) Trade, profession, or particular kind of work


(b) General nature of Industry, business, or establishment In which employed (or employer)


· BIRTHPLACE (State or country)


10 NAME OF FATHER


PARENTS


12 MAIDEN NAME OF MOTHER


1/1


1ª BIRTHPLACE OF MOTHER (State or country)


1, Portugal


"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


/


Filed


191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Nov. 29 . 1915


(Month)


(Day)


(Year)


17 I HEREBY CERTIFY that I attended deceased from Nov. 23 1915, to Nov. 29, 1915 that I last saw ham alive on Nov. 28 1915 and that death occurred, on the date stated above, at 7:45 Am. The CAUSE OF DEATH* was as follows :


Congenital atelectasia.


....... (Duration) ........... ... yrs. ............... mos. ds.


Contributory.


(SECONDARY)


(Duration) .yrs. .........


mos. ds.


(Signed)


Edmund Fi moran


M.D.


Nov.29, 1915


(Address).


664 Bennington St., S. Boston


* 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. In the State .......... yrs. mos.


Where was disease contracted, If not at place of death ?. Former or usual residence


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL VIL CO. 1915


" UNDERTAKER


ADDRESS


al


................. yrs. mos. 6 ds.


11 BIRTHPLACE OF FATHER (State or country)


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occu- pation 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 ou the first line will be sufficient, c. g., Farmer or Planter, Physician, Compositor, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in inany 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 laborcr, 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 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 occu- pation whatever, write None.


Statement of cause of death. - Name, first, the DIS- EASE 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) ; Tuher-


culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles; Whooping cough; Chronic valvular heart disease; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless imn- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acınia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "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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