USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 13
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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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