USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 20
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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, (3) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The matorial 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- 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 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- neumonia (" 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. 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
Millbury, Mass.
(No.
Orchard
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
(Home of Mrs C.H.Smith)
FULL NAME
Adelina May White
[If married or divorced woman or widow give maiden name, also name of husband.]
Adelina May Smith
wife of William E.White
Registered No. 41
@RESIDENCE
Winthrop, Mass.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
June
20
3
(Month)
(Day)
191
(Year)
6 DATE OF BIRTH
May
9
1875
(Month)
(Day)
7 AGE
If LESS than
day ...
38
.yrs.
1
mos.
11
ds.
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)
(Duration)
5
yrs.
mos. ds.
Contributory.
(SECONDARY)
(Duration)
.yrs.
.mos. ds.
(Signed)
Albert G.Hurd
M.D.
une 21
191
(Address)
Millbury, Mass.
* 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 not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
Central Cemetery
DATE OF BURIAL
June 23.
1913
(Address)
M: 11bury , Mass.
Filed July 8
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
10 NAME OF
FATHER
Charles H.Smith
11 BIRTHPLACE
OF FATHER
(State or country)
Burlville, R.I.
12 MAIDEN NAME
OF MOTHER
Lillia P. Putnam
18 BIRTHPLACE
OF MOTHER
(State or country)
Millbury, Mass.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs Lillia P.Smith
REGISTRAR
@UNDERTAKER
Herbert A.Ryan
ADDRESS
Millbury, Mass.
3 SEX female
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
17 I HEREBY CERTIFY that I attended deceased from
(Year)
Apr.29
1913
to
June 20
191
3
....
that I last saw h
.... eralive on
June 20
3
and that death occurred, on the date stated above, at
12. 30
.. m.
The CAUSE OF DEATH* was as follows :
Pulmonary Tuberculosis
-
9 BIRTHPLACE
(State or country)
Millbury, Mass.
Millbury
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Procise 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 nceded. 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-
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
YPLACE OF DEATH
2/
(No.
Shriley
Retia hi :. Donald
C FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
17 Summer Road learnibuduc mass
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
8 SEX
7
4 COLOR OR RACE
W.
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1ª DATE OF DEATH
June 21
(Month)
(Day)
(Year)
6 DATE OF BIRTH
4
191
(Year)
7 AGE
...
4 yrs.
7
mos.
17
da.
....
„.min. ?
$ OCCUPATION
(a)' Trade, profession, or
particuler kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
.(Duration).
5 mos. 20
ds.
.. yrs.
Креманом
Contributory.
(SECONDARY)
(Duration)
...........
... yrs.
mos.
ds.
......
M.D.
191 .....
(Address).
Cambridge
* 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.
" PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
It Paule Galinaton firme 22, 1993
" UNDERTAKER
8. 8. le overran
1
ADDRESS
Filed 191
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
191.3 ... , to
that I last saw h_ alive on Que 10 191 .... 3. and that death occurred, on the date stated above, at 4 &m.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
Cambridge
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country}
Prince Edward Island.
12 MAIDEN NAME
OF MOTHER
Mary Jane Hogan
13 BIRTHPLACE
OF MOTHER
(State or country)
Orange mars.
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) A LO
Lio mi Donald
(Address)
17 Summer Rd. Cenabudy
16
St. ;... Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
191-3
(Month)
(Day)
If LESS than
1 day ......... hrs.
18 NAME OF
Lio. In: Dowald.
(Signed)
Georg & Flla facture
0
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statemont of occupa- tion is very important, so that tho relative hcalthfulness of various pursuits cau be known. The question applies to each and every person, irrespectivo of age. For many occupations a single word or torm 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 iu 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 definito 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 DEATII, stato 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 diseasc. Examples:" Cerebro-spinal fever (the only definite synonym is " Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid usc 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) ; 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- acmia " (merely symptomatic), " Atrophy," "Collapse," " Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," otc., when a dofinite 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 conditious must be referred to tho Medical Examiners:
1. Deaths following injury or violenco, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
8. 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1913. WALTER L LORD
CITY OF BOSTON.
FULL NAME
185 ST. BOTOLPH ST.
Place of Death
Boston
and Residence S
JUNE 23
Date of Death
1913.
Age
44
years
months days.
STATISTICAL DETAILS.
SEX
COLOR
M
SINGLE, MARRIED, WID., DIV. MAR.
Maiden Name
Husband's Name
IPSWICH
Birthplace
Name of
Father ROBERT LORD
Birthplace of Father
Maiden Name
of Mother
Birthplace of Mother ..
Occupation SALESMAN
Informant
Place of Burial
WINTHROP (WINTHROP CEM)
or removal
Undertaker. W. C.SKAGGS
Filed
JUNE 26
1913.
A true copy. Attest :
WINTHROP
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
1913,
from 1913, to. that to the best of my knowledge and belief death occurred, on the date stated above, and that the CAUSE OF DEATH was as follows :
RAR'S
.S
ASPHYXIATION ( ILL GAS ) SUICIDAL -
Primary (Duration}
FFICI
BO3TONIA
TON HITAA
13D.
HE .PONATA A
N. MASS
Contributory · ? ( Duration) 1
(Signed)
W. H. WATTERS
M.D.
JUNE 239|3
...... . .....
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
WINTHROP (223 LINCOLN ST) Usual Residence
Registrar.
IS
T PATRILA
CITY :R
Inais
TA A 1822
ITIS REGIMIN
BOSTON
Registered No .. 6043
1
-
-
June 23-1913
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 Winthrop
(No.
27 Pleasant PK. RSt. ;
Ward)
Martha a. Moulton,
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] a RESIDENCE Wielkiof Mars- 27, Pleasant Ph Od Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
marked
6 DATE OF BIRTH
10 (Month)
28
(Day)
(Year)
7 AGE
If LESS than
[ day ........ hrs.
74 yrs
8
mos.
28 ds.
Or ........ min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
ethome
(b) General nature of industry,
business, or establishment in
which employed (or employer)
Valvular Heart Deseas
Indefinido
(Duration)
yrs.
mos. ds.
Contributory.
aceite nephritis
(SECONDARY)
.(Duration)
yrs. ....
mos. ds.
(Şıgned)
my Parten
M.D.
ene 29, 199 (Address).
Nunchuoto Mano.
* 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.
1$ PLACE OF BURIAL OR REMOVAL & Raudacht Vit
DATE OF BURIAL
7-1-
1913.
ADDRESS
Filed
191
REGISTRAR
16 DATE OF DEATH
1838
17
I HEREBY CERTIFY that I attended deceased from
nov. 1ch
19123., to ...
Veen 2800
1913,
.......
that I last saw het alive on
Aucune 27,
191.2.
and that death occurred, on the date stated above, at
5.a.m.
The CAUSE OF DEATH* was as follows :
' BIRTHPLACE
(State or conntry)
Eden V.t.
10 NAME OF
FATHER
Food Plundy
PARENTS
11 BIRTHPLACE OF FATHER (State or conntry)
12 MAIDEN NAME
OF MOTHER
Surah Dudley
18 BIRTHPLACE
OF MOTHER
(State or conntry)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informsnt)
Clyche Di Moulton
(Address)
(City or town.)
[lf death occurred in a hospital or institution, give its NAME instead of street and number.]
1913.
(Month)
28
(Day)
(Year)
20 UNDERTAKER
we. skaggs Wirlium.
June 28-1913.
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-
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
Metcalf Hospital No. 176 Wiecchio
Hettie
Martha Jucken Floyd.
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
36 Center St Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
w
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
6 DATE OF BIRTH
13
(Day)
(Year)
7 AGE
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