USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 121
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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 .. 225 Pleasant
St. ;.. ...... Ward)
Jeremiah Carlos Blake
? FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
225 Pleasant SL
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
' COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manus
· DATE OF BIRTH nov 13 (Month)
(Day)
1 (Year)
? AGE
69 . 1
mos.
15
ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or particular kind of work
(b) General nature of industry,
business, or establishment In
which employed (or employer)
Polui oficio
9 BIRTHPLACE
(State or country)
Hardwellmer
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
de show me
12 MAIDEN NAME
OF MOTHER
Eliza Centro
18 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
C. Rivera
-
(Address)
REGISTRAR ....
...
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Registered No. ....
18 DATE OF DEATH
(Month)
29
1915
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from 1913 191 .,
to Dec 29 1915 that I last saw hw alive on 1915 and that death occurred, on the date stated above, at 7.30m. The CAUSE OF DEATH* was as follows :
apoplefry
(Duration)
1
... yrs.
...........
„.mos.
......... ds.
Contributory
(SECONDARY)
.. (Duration)
ayrs.
.....
mos.
ds.
( 31) milanes
M.D.
(Signed)
De 30
....
, 19156
(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).
In the
At place
of death
yrs.
.mos.
ds.
State ............ yrs.
mos.
ds.
Where was disease contracted, If noi at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Muchoto Comela
DATE OF BURIAL 31 1914 191.5
20 UNDERTAKER
ADDRESS
Filed 191
10 NAME OF
FATHER
Benjiman, H,
If LESS than I day ........ hrs.
1846
...
....
ʹ
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 fircman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, 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 Housc- 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 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 Nonc.
Statement of cause of death. - Namc, 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 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," unqualificd, 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); Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced 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 ascertaincd as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
3
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, 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 dcad, ctc.
1 1
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.
PARENTS
LI BIRTHPLACE
OF FATHER
(State or country)
Maino
Cortland
12 MAIDEN NAME
OF MOTHER
analy DEaton
18 BIRTHPLACE
OF MOTHER
(State or country)
Boston
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
George Vodder
(Address)
149 Locust It
14
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec
29'
(Month)
(Day)
191.
......
(Year)
18
17
I HEREBY CERTIFY that I attended deceased from
June 26, 1915, to
1- 29
1915
that I last saw halive on
Dec 28
191.50
1
and that death occurred, on the date stated above, at 2:15 Am.
The CAUSE OF DEATH* was as follows :
Cerebral Hemmlage
.(Duration)
........ yrs. ................ mos.
.....
ds.
Contributory.
Inarditis, Chemin
....
(SECONDARY)
... yrs. .
mos.
.. ds.
(Signed)
M.D.
Dann 29, 1915 (Address) 355 Lmelaf8
* 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.
Where was disease contracted, If not at place of death ?.
Former or usual residence.
1 PLACE OF BURIAL OR REMOVAL Hunthrow
DATE OF BURIAL
O EC 31, 1915
20 UNDERTAKER
form J. Finally
ADDRESS
Hinterop
[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
' COLOR OR RACE
ambito
$ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Midauvedl
* DATE OF BIRTH
Oct
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day ......... hrs.
or ...... in. ?
* OCCUPATION
(a) Trade, profession, or
particular kind of work
"Aret Forman
(b) General nature of industry.
business, or establishment
which employed (or employer).
Aswepaper mailing Deft
9 BIRTHPLACE
(State or country)
Boston
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town.)
' PLACE OF DEATH
(No.
149 Locust
Charlie Henry Thomas Todd
O tharfeel
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
149 Locust It
St.
Ward)
63 yrs. 2
.yrs.
mos.
21
ds.
10 NAME OF
FATHER
NEal
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean 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 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) 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, ete. 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 domestie service for wages, as Servant, Cook, Housemaid, ete. 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 oecu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affeetion 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 "Epidemie 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 need not be stated unless im- portant. Example: Measles (disease eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," " An- aemia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age,". "Shock," "Uraemia," "Weakness," ete., when a definite disease ean be ascertained as the eause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia,". "PUERPERAL peritonitis," ete. State eause 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 eaused 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.
(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 .......
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 191, MIVEL Cd,
St. ;.
Ward)
* FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
191 Mois
11
Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
10cc
30
(Month)
(Day)
1915
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Con 1020 30
191_S_, to
191-
that I last saw her alive on
Lesc 15
191
5
..........
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH" was as follows :
angina Pectoris
Did a surgical operation precede death ?
Date
1 hour.
(Duration).
... yrs. ..
mos.
ds.
Contributory (SECONDARY)
(Duration) . .............. yra. ....
mos. .............. ds.
(Signed)
Edward J. Franger
M.D.
2020 31
1915 (Address).
49 Bartlett Rd.
* If death followed Injury or violence the certificate of death must be made out by the Medical Examiner.
1 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
.......... yrs.
.. mos.
In the
ds.
State ............ yra.
............ mos.
........
„ds.
Where was disease contracted, If not at place of death ?. Former or usual residence.
1ª PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
191.6.
20 UNDERTAKER
ADDRESS
Filed , 191
-
REGISTRAR
.........
(City or town.) [If deeth occurred in e hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
4
(Month)
(Day)
1
(Year)
If LESS then
I day ......... hrs.
54 „yrs. mos. .............
ds.
.min. ?
2
11 BIRTHPLACE
OF FATHER
(State or country)
télmed.
18 BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)
191
5
$ SEX € $ DATE OF BIRTH 7 AGE · OCCUPATION (a) Trade, profession, or 1 particular kind of work * BIRTHPLACE (State or country) 10 NAME OF FATHER elvive 12 MAIDEN NAME OF MOTHER PARENTS WHITE PLAINS, WHITE UNTADING IN THIS IS A PERMANENT RECORD. (b) General neture of Industry, business, or esteblishment which employed (or employer).
BOSTON
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 houschold only (not paid Housc- 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 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 diseasc. Examples: Cerebro-spinal fevcr (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (ncver 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, ctc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mercly 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 septicaemia," "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 strcet, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dcad, ctc.
important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should stato CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very PARENTS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
' PLACE OF DEATH
Muchos
(No.
23
Atlantic
St.
„Ward)
(City or town.) ...
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
? FULL NAME
Phares L. Woods
[If married or divorced woman or widow give maiden name, also name of busband.] @RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
& SEX
' COLOR OR RACE
W
5 SINGLE.
MARRIED
WIDOWED,
OR DIVORCED
( Write the word)
names
$ DATE OF BIRTH
11 (Month)
4
(Day)
(Year)
7 AGE
if LESS than [ day ......... hrs.
44 yrs.
17
mos.
26 ds.
min. ?
OCCUPATION
(a) Trade, profession, or
particular kind of work ....
(b) General nature of Industry, business, or establishment which employad (or employer).
* BIRTHPLACE
(State or country)
Provincetown Wars.
10 NAME OF
FATHER
John woodo
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE
OF MOTHER
(State or country)
wales
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Addrass)
23 attente st
Filed 191
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
1912, to Les 30 1915 .... that I last saw he alive on Den 30 1910 and that death occurred, on the date stated above, at 240 am. The CAUSE OF DEATH* was as follows : Cardini Dicacao
Mitral Requintado & Obstruction
(Duration) ...
............ yrs.
mos .. ds.
Contributory
.... (SECONDARY)
.(Duration)
Z
mos.
................ yrs. ............ ds.
(Signed)
M.D.
Jan 1
1916 (Address)
218 mamita Macho
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
16 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In tha
At placa
of daath ............ yrs.
mos.
ds.
State ............ yrs. ...
mos.
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Provato con la
DATE OF BURIAL
1-3-195
20 UNDERTAKER W.C. Skaago
ADDRESS
16 DATE OF DEATH
Du
(Month)
30
1915
(Year)
(Day)
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preeise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean 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) 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 Housc- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and ehildren, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestie serviee 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 oecu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Ccrebro-spinal fcver (the only definite synonym is "Epidemie 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, ete., Carcinoma, Sar- coma, ete., 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: Measles (disease eausing 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," ete., when a definite disease ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State eause for which surgieal operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing eonditions must be referred to the Medieal Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused 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 eircumstances 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 stato 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.
23
accare Viene
St.
.
.. Ward)
" FULL NAME
Cast. Henry G. aller
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Winthrop. 13 ( ccan view st
.... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
m
' COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
19
med .
(Day)
(Year)
* DATE OF BIRTH
9
(Month)
17
(Dáy)
1831
(Year)
7 AGE
3.50 yrs. ..
32
mos.
1 40%.
.... min. ?
* OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired Sia Captain
(b) General nature of industry,
business, or establishment
which employed (or employer)
· BIRTHPLACE
(State or country)
Allendale 4-5-
PARENTS
12 MAIDEN NAME
OF MOTHER
Mary Vaughn
13 BIRTHPLACE
OF MOTHER
(State or country)
Horton 2.8.
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)que Horay a. alle
(Address)
23 Ocean Here
REGISTRAR
16 DATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
1 30
1915
to
1915
that I last saw hai
alive on
Der 31 1
1915
and that death occurred, on the date stated above, at.
5:15pm.
1
The CAUSE OF DEATH* was as follows :
Lobby l'neunuma
(Duration)
......... yrs.
mos.
3
ds .
Contributory.
(SECONDARY)
(Duration)
.... yrs.
mos.
ds.
(Signed)
Jan 22
.....
* H 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
1-3 - 1912
D UNDERTAKER W.C. Sagan.
ADDRESS
-
Filed 191
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
(Month)
31
191.
5
......... ...... yrs. ......
If LESS than
1 day ......... hrs.
10 NAME OF
FATHER
ambrose allen
11 BIRTHPLACE
OF FATHER
(State or country)
.......
M.D.
1916 (Address)
....
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, Laborcr - 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- CASE 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 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 discase 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 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 one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
نعم
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