Town of Winthrop : Record of Deaths 1913-1915, Part 28

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 28


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


culosis of lungs, meninges, peritonacum, etc., Carcinoma, Du coma, etc., of. ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasins) ; Measles; Whooping cough; Chronic valvular heart disease; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless in- 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," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracnia," "Weakness," ctc., when a definite disease can be ascertaincd as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septieacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine definitely. " Examples: "Accidental drowning; Struck by railway train - accident; Revolver wound cf head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. g., sepsis tetanus) may be stated under the head of "Contributory."


Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be duc 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


(City or town.) Boston Harbor Ofhinteroft Ware


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


2 FULL NAME


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


84 Nest Rutland Square 17


Registered No 28586


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


4 COLOR OR RACE


¿ SINGLE,


MARRIED,


WIDOWED,-


OR DIVORCED


(Write the word)


Single


6 DATE OF BIRTH


unknown.


(Month)


(Day)


(Year)


7 AGE


24


yrs. - mos. -


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


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Walter


(b) General nature of industry,


business, or establishment in


which employed (or employer).


9 BIRTHPLACE


(State or country)


Lowell Maar


PARENTS


12 MAIDEN NAME OF MOTHER


New York


Ellen O' Brien


1ª BIRTHPLACE OF MOTHER (State or country)


Proton mass


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


William Flumin


(Address)


Filed


REGISTRAR


16 DATE OF DEATH


Debt


(Month)


(Day)


1913 (Year)


17 1 HEREBY CERTIFY that I have investigated the death of the deceased.


The CAUSE OF DEATH* was as follows 010 stated This man was in a Dory off the Misthampshire and Dept. 11.1913-The Dary was phuck byla Aquale, capsized and he was drowned(Duration) .yrs. .. mos. ds.


Contributory


(SECONDARY)


.. (Duration)


.. yrs.


mos.


ds.


(Signed)


Cour Richardson


M.D.


Dept 22 193 (Address) associate MEDICAL EXAMINER bonsity s Arefree


* 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.


mr.os.


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


Onder markt


DATE OF BURIAL Sept24. 191.3.


20 UNDERTAKER


ADDRESS


Edu. teamney &Jon 29 9hackers2


11


If LESS than


I day, ....


.„hrs.


10 NAME OF


FATHER


Martin Flynn


11 BIRTHPLACE OF FATHER (State or country)


In the


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. g., Farmer or Planter, Physician, Compositor, Architcet, 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 House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.


Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal 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," unqualificd, 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) ; Mcasles; Whooping cough; Chronic valvular heart disease; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced not be stated unless im- portant. Example: Measles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An-


aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age,"


"Shock," "Uracmia," "Weakness," etc., when a definite discase 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. For VIOLENT DEATHS State MEANS OF INJURY and qualify as ACCI- DENTAL, 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 carbolie acid - probably 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 provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


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


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Hinthigh .(No 62 Birch Rd


St. : Ward)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Male


' COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


married


$ DATE OF BIRTH


April


15


1860


(Month)


(Day)


(Year)


7 AGE


53


.. yrs.


5


mos.


-


ds.


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


$ OCCUPATION


(a) Trade, profession, or


particular kind of work


Real Estate


(b) Ganaral natura of industry, businass, or establishment In


which employad (or employer).


· BIRTHPLACE


(State or country)


Enfield N. S.


10 NAME OF


FATHER


Edward Powers


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Dicland


12 MAIDEN NAME OF MOTHER Margaret Green


13 BIRTHPLACE


OF MOTHER


(State or country)


Ireland


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Annie Mc Donnell


(Address)


62 Birch Road


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


10 DATE OF DEATH


Self


15


1913


(Month)


(Day)


(Year)


17 I HEREBY CERTIFY that ! attended deceased from


to


1913


Sift 15


1913


4


that I last saw him alive on


191


51114


3


and that death occurred, on the date stated above, at & a m.


The CAUSE OF DEATH* was as follows :


Pernicious anaemia


(Duration)


1 yrs.


......


mos.


ds.


Contributory


(SECONDARY)


.(Duration)


yrs. .......


mos.


ds.


(Signed)


Salt 13


21 Metcalf


M.D.


1913 (Address)


Winthrop 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).


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


18 PLACE OF BURIAL OR REMOVAL At aubum Com.


DATE OF BURIAL


Sept 17


1913


20 UNDERTAKER John + O'malley


ADDRESS


Winthrop


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.


Winthrop


James Edward Powers ouverSI


2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE


Filed 191


If LESS than


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


Jeps . 15


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can he 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 " Lahorer,""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 cerehro-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 he 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 childhirth 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 disahled 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


A PLACE OF DEATH


1


Winthrop


(No


56 Locust St


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


MEDICAL CERTIFICATE OF DEATH


3 SEX


' COLOR OR RACE


Female Mute


5 SINGLE,


MARRIED,


WIDOWED,


OR -DIVORCED


(Write the word)


16 DATE OF DEATH


Sept.


16


1913


(Month)


(Day)


(Year)


A DATE OF BIRTH


(Month)


(Day)


(Year)


7 AGE


If LESS than


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


or ......


min. ?


a OCCUPATION


(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)


Winthrofi.


10 NAME OF


FATHER


Simon & Cassidy


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Boston


12 MAIDEN NAME


OF MOTHER


Mertrude In Voller.


1ª BIRTHPLACE


OF MOTHER


(State or country)


Breton


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


/


Tres passedy


/ (Address)


56 Locust


REGISTRAR


17


I HEREBY CERTIFY that I attended deceased from


Sept-16


191.3 ... , to


Sept 16


1913


that | last saw h ....


alive on


191.


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


.m.


The CAUSE OF DEATH* was as follows :


Stillfor


.(Duration)


.yrs.


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


ds.


Contributory


(SECONDARY)


(Duration) ... yrs.


mos. ds


(Signed)


Harrey afell


........


M.D.


Sept 17, 1913 (Address) 32; Withno


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


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


At place


of death


. yrs.


mos.


in the


ds.


State ............ yrs.


mos.


ds .............


Where was disease contracted,


If not at place of death ?.


Former or usual residence.


19 PLACE OF BURIAL OR, REMOVAL so Muchna Den


DATE OF BURIAL


-SET IT. 199


20 UNDERTAKER,


ADDRESS


Il mio


Filed 191


Stillborn Cassidy 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE


1


yrs.


.. mos.


ds.


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 deathis 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


(City or town.)


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


2 FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 66 Stevie


Que


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH Left (Month)


17


(Day)


, 1846


(Year)


7 AGE


If LESS than | day, ... ... hrs.


6% yrs. - mos.


ds


or min. ?


& OCCUPATION


(a) Trade, profession, or particular kind of work.


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


9 BIRTHPLACE


(State or country)


trecerector 2.13


1


10 NAME OF


FATHER


allin


Jenta


PARENTS


11 BIRTHPLACE OF FATHER (State or country) the tractor 413


12 MAIDEN NAME OF MOTHER


13 BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


Filed 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH Seph. (Month)


17


1951


(Year)


I HEREBY CERTIFY that I attended deceased from nor. jest 191.1., to Refah. 17 , 191.49,- that I last saw her alive on Depth. ×5 , 1913., and that death occurred, on the date stated above, at ... 1.9.m. The CAUSE OF DEATH* was as follows :


(Duration) 2


yrs. .


mos.


ds.


Contributory (SECONDARY)


(Duration) .


V


yrs. .


mos. ..


ds.


(Signed)


I.t. Porter


,


M.D.


Vebl. /17191


.... (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


12 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL Sept 1.7. 191


20 UNDERTAKER


ADDRESS


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.


1 PLACE OF DEATH


(No


Ilorigen


Ward)


(Dấy)


17


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.




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