Town of Winthrop : Record of Deaths 1913-1915, Part 13

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 13


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, Gas Poisoning, Suicide, Ilomicide, 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 important. See instructions on back of certificate.


3 SEX $ DATE OF BIRTH 7 AGE 8 OCCUPATION Trade , PARENTS (Informant) CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very particular kind of work


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Wendlerof Horhetic ( No. Walking FL ...


St. : ....


Ward)


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


Milletin. G. Barry 2 FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 144 Concurs- Road Winthrop


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


april


14, 1913


(Montlı)


(Day)


(Year)


1983 17 I HEREBY CERTIFY that I attended deceased from Imarch 23 , 1913 , to april 14, 1913, that I last saw h alive on april 14, 191.3. and that death occurred, on the date stated above, at 8. 30Pm. The CAUSE OF DEATH* was as follows : Chemin Valvula Heart Diease Chemin Interstitial nephritis


.(Duration)


yrs.


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


ds.


Contributory (SECONDARY)


.(Duration) ...


yrs. ..


mos. .


ds.


(Signed)


Charles 7. mahoney


M.D.


april 15, 1913 (Address)


355 Winters 56


* 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 4./15, 1913


10 UNDERTAKER


ADDRESS


16 Filed .. 191


REGISTRAR


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Senje.


6ch


14


(Month)


(Day)


(Year)


If LESS than I day,. hrs.


29 yrs. 6 mos. . 2 . ds.


or ....... min. ?


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


Panit-8 day Stans


9 BIRTHPLACE (State or country) " Cheyenne Wyoming


10 NAME OF


FATHER


James . W. Barry


11 BIRTHPLACE OF FATHER (State or country) Charlestown Mes


12 MAIDEN NAME OF MOTHER Vielen. G. Black


1ª BIRTHPLACE OF MOTHER (State or country}


-


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Address)


Wunschet


(City or town.)


registered No.


4 COLOR OR RACE


White


WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.


In the


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, Loeo- 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 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 cercbro-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., C'arcinoma, 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," "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 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.


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


II BIRTHPLACE


OF FATHER


(State or country)


Icollant


12 MAIDEN NAME


OF MOTHER


1ª BIRTHPLACE


OF MOTHER


(State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant) ..


Frank Handy


(Address)


29 Bear Ska Muntert


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


april.


145


191.3


(Month)


(Day)


(Year)


17 I HEREBY CERTIFY that I attended deceased from april 199


to


april 14


1913


that I last saw het alive on


april


1913


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


1230,


m.


1


The CAUSE OF DEATH* was as follows : Metral regurgitation


(Duration) .


3


yrs.


mos.


ds.


Contributory


Senility


(SECONDARY)


(Duration)


yrs.


mos.


...


ds.


(Signed)


april / 191.


.13 (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 4/16


,


191


20 UNDERTAKER


ADDRESS


Filed 191


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(No). 29 Beak


St. ;... ...


... ...


Ward)


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


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


(Month) (Day)


(Year)


7 AGE


If LESS than l day, .... hrs.


yrs.


mos. .


ds.


or min. ?


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


at Home


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


Keeping House


9 BIRTHPLACE


(State or country)


Glosco I collant


10 NAME OF


FATHER


Samuel Hawthorne


Joule


M.D.


(City or town.)


Fannie Cun Hanly 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 2ª Beak Ht viculturapo maz


Widow of Francis


Hanby


Registered No.


WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.


-


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, Luborer - 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 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, Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-


calosis of lungs, meninges, peritoneum, etc., Carcinoma, Sur- 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 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, Fulls, 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-1913. MATHIAS COWEN


CITY OF BOSTON. 3690


FULL NAME


Registered No


BOSTON CONS.HOSPT.


Place of Death ¿


Boston


and Residence S


APR. 14


50


Date of Death


1913.


Age


years


months. days.


STATISTICAL DETAILS.


SEX


COLOR


SINGLE, MARRIED, WID., DIV.


M


W


MAR.


Maiden Name


Husband's Name


BOSTON


Birthplace


JAMES COWEN


Name of Father


Birthplace of Father


IRELAND


Maiden Name of Mother ...


IRELAND


Birthplace of Mother.


NONE


Occupation


Informant


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


from 1913, to


1913, 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 :


EG


UT PATRI


MAUS. SITDE Primaryo (Duration)


PULM. TUBERCULOSIS -


3 YRS. 4 MOS. 16 DAYS


N. MASS Contributory : LARYNGEAL TUB. 1 MO.8 DYS (Duration)


(Signed)


J. E. OVERLANDER


.M.D.


APR. 14


1913


SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.


Place of Burial or removal


MT. BENEDICT


T. J. LANE


Undertaker


Usual Residence.


WINTHROP (24 OAKLAND ST)


APR.17


Filed . 1913.


A true copy.


Attest :


Eringlenen


Registrar.


MARGIN RESERVED FOR BINDING.


IS


TRAR'S


R


SICUT


CITY


BOSTONTA COMPITA A. 1822 TISREGIMINE-DONATA A BOST 1631 ..


......


apr. 14 - U -


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


13 BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


CK. Ben __


(Address)


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH april 16, 1913 (Year)


gionth)


(Day)


17 I HEREBY CERTIFY that I have investigated the


death of the deceased.


The CAUSE OF DEATH* was as follows :


natural Causes:


Heart disease, organic.


probably Corman Sclerosio.


-


(Sund der Pour desmartyrs.)


... mos.


ds.


Contributory


(SECONDARY)


(Duration)


.. yrs. .


. mos.


ds.


M.D.


april 16, 1913 (Addres).


2.30 P


MEDICAL EXAMINER


* State the DISEASE CAUSING DEATH, 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 place


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


DATE OF BURIAL


4/20


193


ADDRESS


20 UNDERTAKER € 122


0030


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Winthrop (No. 15)


2 FULL NAME Charles Q. Pike [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE in from are


St. : Ward)


(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


3 SEX


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


marsel


6 DATE OF BIRTH


1850


( Das)


(Y)ar)


7 AGE


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


58 yrs. yrs.


mos. ds.


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


8 OCCUPATION


(a) Trade, profession, or Salesman


particular kind of work


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


Boots& Shoes


2 BIRTHPLACE


(State or country)


Gorham ml


10 NAME OF


FATHER


William Pike


(Signed)


Linz Buyers Maguado,


11 BIRTHPLACE OF FATHER (State or country)


Filed ., 191


The Commonwealth of Massachusetts


WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.


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, Loeo- 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-


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 .; 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 diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident ; Revolver wound of head-homicide ; Poisoned by carbolic acid - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of " Contributory."


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


automobile Frituren 783 Sterile Ward)


St. and metcalf Hospital


-


5041 winthrop (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


3 SEX


4 COLOR OR RACE


W


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Single.


$ DATE OF BIRTH


3


(Month)


30


(Day)


1900


(Year)


7 AGE


If LESS than I day, ........ hrs.


10 yrs.


mos.


200s.


or ...


. min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Student


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


9 BIRTHPLACE


(State or country)


Medford War.


10 NAME OF


FATHER


Leslie E. Griffin


11 BIRTHPLACE OF FATHER (State or country) Marie


12 MAIDEN NAME


OF MOTHER


Lucy F. Riley.


18 BIRTHPLACE


OF MOTHER


(State or country)


Cambridge


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Leslie & Griffin


(Address)


117 Bartlett Road.


REGISTRAR


16 DATE OF DEATH akul 19 1913


(Month)


(Day)


(Year)


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


The CAUSE OF DEATH* was as follows : Fracture the Skull wet associated contusions ofthe Brain, harmonhage and Shock, caused bybering ac Cidentitty Stanach.


ds.


Contributo Rehice.


(SECONDARY)


(Duration)


..... yrs. .


mos.


ds.


(Signed)


Som Burgers Magnathis.


Cijene 19, 191.


(Address)


1. OSPV MEDICAL EXAMINER


* State the DISEASE CAUSING DEATHI, 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 place


of death.


.. yrs.


mos.


ds.


State


.yrs.


.mos.


.. ds ..


Where was dlsease contracted, if not at place of death ?.


Former or usual residence ..


19 PLACE OF BURIAL OR REMOVAL ghintheop Pecc.


DATE OF BURIAL


4 -22. 1913


20 UNDERTAKER


IfC. Skargi


ADDRESS


Filed. . .. , 191


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


WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.


important. See instructions on back of certificate.


PARENTS


2 FULL NAME


arthur friggin


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 112 Bartlett Road


Registered No.


M.D.


In the


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, o. 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, (3) 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 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.




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