Town of Winthrop : Record of Deaths 1913-1915, Part 16

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 16


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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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 .; 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, 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, etc.


CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 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.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(No. 6/ Coral an St. :


Ward)


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


Lydia Marcha frost


2 FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 6/ coral


Rufen. W. Frost (undowo


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


18 49


(Month)


(Day)


(Year)


7 AGE


64


.yrs.


2


mos.


17


ds.


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


3 OCCUPATION


(a) Trade, profession, or


particular kind of work


as Home


(b) General nature of industry,


business, or establishment in


which employed (or employer).


· BIRTHPLACE


(State or country)


3) I andreun M.B.


10 NAME OF


FATHER


Unchen Greenlaw


11 BIRTHPLACE


OF FATHER


(State or country)


Scott(


12 MAIDEN NAME


OF MOTHER


Cederain Grandan


1ª BIRTHPLACE


OF MOTHER


(State or country)


new Brunswick


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


le RBemma


(Address)


water / mas


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


17


I HEREBY CERTIFY that I attended deceased from


app 201


......


to


1913


may ?


1913


that I last saw h 02


alive on


matin


1913


and that death occurred, on the date stated above, at / 30pm.


The CAUSE OF DEATH* was as follows :


General arterio schernis


Cerebral hemorrhage


(Duration)


yrs. ..


mos.


1X


ds.


Contributory. (SECONDARY)


(Signed)


(Duration)


310 metcull


M.D.


mos.


ds.


yrs.


may 9, 1913 (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.


In the


mos.


ds.


State.


yrs.


....


Where was disease contracted,


If not at place of death ?.


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


5/9


1913


20 UNDERTAKER


Combuga


Filed 191


....


16 DATE OF DEATH


may


(Month)


(Day)


3


1913


(Year)


6 DATE OF BIRTH


22


If LESS than


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


PARENTS


WRITE PLAINLT, WIEN UNPAVING INA - INIS IS A PERMANENT RECUKU.


(City or town.)


ADDRESS warrell-


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," " Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.


Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-


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 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.


-


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


Maryaut Ologin


13 BIRTHPLACE


OF MOTHER


(State or country)


Suland


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month)


>


191-3


(Day)


(Year)


17


I HEREBY CERTIFY that I attended deceased from


111 ay


5


1913 ... ,


to


111 ay 7


191 3


that I last saw he alive on


111 cm


7


191 3


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


10 Am.


The CAUSE OF DEATH* was as follows :


Pneumonia. (Lobar)


(Duration) .


...........


.yrs.


............. mos. ds.


Contributory. (SECONDARY)


(Duration)


.. yrs.


mos.


ds.


(Signed)


Howray


art elle


M.D.


1150


8, 1913 (Address


325 Anthrop Si


* 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 Holy Hood Country Bath


DATE OF BURIAL


May 10, 1912.


20 UNDERTAKER


Filed


191 ....


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Female


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


-


Single.


6 DATE OF BIRTH


(Month)


(Day)


1


(Year)


7 AGE


75 yrs.


mos.


ds.


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


8 OCCUPATION


at Home


(a) Trade, profession, or


particular kind of work


(b) General nature of industry,


business; or establishment in


which employed (or employer).


9 BIRTHPLACE


(State or country)


Juland


10 NAME OF


FATHER


11 BIRTHPLACE OF FATHER (State or country)


Jul


Irland


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


1 PLACE OF DEATH


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH (No. 75 Beach Road


BOSTON


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


2 FULL NAME


mans.


n & halvin


[If married or divorced woman or widow


give maiden name, also name of husband j


@RESIDENCE


St. ;....


Ward)


In the


ADDRESS


54. 9 St 1h


If LESS than


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


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can bo known. Tho 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) Salcs- 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 Ilousc- 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 Nonc.


Statement of cause of death. - Name, first, the DISEASE ('AUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is " Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite; avoid use of " Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," " 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 ouc supposed to be due to Alcoholism, etc.


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


3 SEX m 6 DATE OF BIRTH 7 AGE (a) Trade, profession, or 12 MAIDEN NAME OF MOTHER PARENTS 13 BIRTHPLACE OF MOTHER (State or country) (Informant) Important. See instructions on back of certificate. 16 N. B. - Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very (b) General nature of industry, business, or establishment i which employed (or employer) ..


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


I PLACE OF DEATH Winthrop


(No.


Metcalf Hospilas?


Ward)


'FULL NAME


Henry Price Pronk


.


[If married or divorced woman or widow give maiden name, also name of husband.] aRESIDENCE 294 Bondone St, Withste


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


May


(Month)


(Day)


(Year)


I HEREBY CERTIFY that I attended deceased from


1913, to.


191


May 4"


3.


that I last saw hm


alive on


1913,


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


11:30pm.


The CAUSE OF DEATH* was as follows :


( Lobar )


myocarditis


(Duration)


.. yrs. ................ mos.


9


ds.


Contributory


(SECONDARY)


(Duration)


... yrs.


.mos.


.........


ds.


(Signed)


Fra/0, 1913 (Address)


withop


* 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 death.


.yrs.


..........


mos.


9


ds.


State


......


...


.yrs.


.. mos. ..


ds.


Where was disease contracted,


If not at place of death ?...


244 Bourdon St Wanthop


usual residence.


Former or


244 Bundom &t Wanthop


1º PLACE OF BURIAL OR REMOVAL Cedar la.


DATE OF BURIAL


................ #


191


20 UNDERTAKER Dersin


ADDRESS


Dorchester luce


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Jungle


4


(Month)


10-


1745 17


(Year)


(Day)


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


66 yrs. ... mos. 29 ds.


or.


... min. ?


8 OCCUPATION


Whole Sale Books and


particular kind of work


Street


9 BIRTHPLACE


(State or country)


Dincheater, Mirare.


10 NAME OF


FATHER


Ce device Prouff


11 BIRTHPLACE


OF FATHER


(State or country)


new York.


"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Address)


294 Bourdain St


Filed 191


REGISTRAR


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


.....


1913


.....


M.D.


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation 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-


May 1, 1110


culosis of lungs, meninges, peritonaeum, etc , Carcinoma, Sar- coma, etc., of .... .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL 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.


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(No. 2) alderen 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


Male


4 COLOR OR RACE


White


$ SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


14 1909


(Month)


(Day)


(Year)


7 AGE


3


.. yrs.


11


mos.


16 de.


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


$ OCCUPATION


(a) Trade, profession, or


particular kind of work


at home


(b) General nature of industry,


business, or establishment


In


which employed (or employer).


· BIRTHPLACE


(State or country)


Everetto munisalla


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country) Braceleton Vit


12 MAIDEN NAME


OF MOTHER


Gartudo Watson


18 BIRTHPLACE


OF MOTHER


(State or country)


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


7214 1913.


/Month)


(Day)


(Year)


17


I HEREBY CERTIFY that I attended deceased from


to


thay 14


1913


may 11


1913.


that I last saw hem alive on


2-30 Pm


1913%,


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


.m. The CAUSE OF DEATH* was as follows :


Scarlet Herer


.(Duration)


.yrs.


mos.


3.


ds.


Contributory


(SECONDARY)


(Duration)


.......


.... yrs.


mos.


ds.


(Signed)


Dr.l. Pants


M.D.


than 15.


191 ....


(Address).


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


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


At place


In the


of death.


.... yrs.


.mos.


ds.


State


.yrs.


mos.


ds ..


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


Former or usual residence.


18 PLACE OF BURIAL OR REMOVAL Wiecherof Connelly Toml


DATE OF BURIAL


Since 15, 1913


20 UNDERTAKER


ADDRESS


Wiele


Filed . 191.


Richard. William Frem.


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


Waldenmen are


6 DATE OF BIRTH


If LESS than


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


10 NAME OF


FATHER


Howard. W. Kevin.


WNIIC PLAINLI, WITH UNFADING INN -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, 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.


Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is " Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-




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