Town of Winthrop : Record of Deaths 1913-1915, Part 32

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 32


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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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 duc to Alcoholismi, etc.


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


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


PLACE OF DEATH


Winthrop


(No.


66 PlummerQue


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


Female White


5- SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Midow


" DATE OF BIRTH


(Month)


(Day)


1


(Year)


7 AGE 72


If LESS than


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


.yrs.


mos.


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).


9 BIRTHPLACE


Bedford hince Eduard eland


10 NAME OF


Hugh Macaulay.


PARENTS


12 MAIDEN NAME OF MOTHER Margaret Bronson


18 BIRTHPLACE OF MOTHER (State or country)


J. C. Joland.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


michael . macaulay


(Address)


66 Plumones Que


Filed 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


och


218h


3


(Month)


(Day)


191


(Year)


17


I HEREBY CERTIFY that I attended deceased from


0 0/ 20. 1913.


that I last saw her alive on.


June 15, 19/20


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


5 cm.


The CAUSE OF DEATH* was as follows :


Losis of Live


2


yrs.


8


mos.


ds.


(Duration)


2


Contributory


(SECONDARY)


(Duration)


. yrs.


mos. ds.


(Signed)


Grossem. Multant


M.D.


Och- 22


1913 (Address)


130 Princeton 8%


* 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


Calvary Cemetery Oct 23 1913


20.UNDERTAKER


J. CO. maley


DATE OF BURIAL


ADDRESS 79 CUlantic It


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.


Sarah


Johns


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


widow of Richard forma


.... Registered No.


BOSTON (City or town.)


11 BIRTHPLACE OF FATHER (State or country)


P.E. bland


Oct . 21, 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 caclı 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 engincer, 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 iu the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, IHousework, 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 strect, or one supposed to be due to Alcoholism, etc.


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


The Commonwealth of Massachusetts


1 PLACE OF DEATH


STANDARD CERTIFICATE OF DEATH Monthof (No 22 Hooderde Coc


Minttuoh (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 Female


4 COLOR OR RACE


11 lute


· SINGLE,


MARRIED,


WIDOWED,-


OR DIVORCED


(Write the word) Jingle


6 DATE OF BIRTH


200


(Month)


(Day)


1912


(Year)


7 AGE


If LESS than


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


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


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


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


· BIRTHPLACE


(State or country)


Winthrop have.


1$ NAME OF FATHER


11 BIRTHPLACE OF FATHER (State or country)


East Boelon


colon


12 MAIDEN NAME OF MOTHER li zabeth floods


18 BIRTHPLACE


OF MOTHER


(State or country)


Ireland


14 THE ABOVE IS TRUE TO THE BEST-OF MY KNOWLEDGE


(Informant)


Ichno Loberty


(Address)


22 Woodside QUE


16


Filed


191


REGISTRAR


16 DATE OF DEATH


(Month)


26


(Day)


(Year)


17


I HEREBY CERTIFY that I attended deceased from


Cer 26, 1913, to.


Cet 26 1913


that I last saw


eralive on


and that death occurred, on the date stated above, at )19 m. The CAUSE OF DEATH* was as follows :


for tuno.


(Duration)


yrs.


mos.


Contributory


(SECONDARY)


(Duratien)


.......... yrs.


mos.


.........


ds.


(Signed)


- Harrey all elly


M.D.


Cet 28 1913 (Address)


325 Winch


.....


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


16 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 Holy Cow Ceny


DATE OF BURIAL


Oct 20, 1913


20 UNDERTAKER


oli f maley


ADDRESS


79 Atlantic


Pinchaof


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.


.


·


Anna Marco Doherty


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


22 Hordoide Are.


Ward)


191.3.


4


10


mos.


22


ds.


.yrs.


PARENTS


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 terui 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 chauged 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 affectiou with respect to time and causatiou), 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, peritoneum, etc., Carcinoma, Sar- coma, etc., of ... .. (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasuis) ; Mcasles ; 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 deatlı), 29 ds .; 1 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," " Wcakness," 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 operatiou was uudertaken.


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


Writtenon Man (No.


15 Bates Cv


St. ;....


Ward)


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


Caroline, amelia Tewksbury


wife of


Russell Tewksbury


Registered No.


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month)


29. (Day)


0 (Year)


I HEREBY CERTIFY that I attended deceased from


1918


Ord 29


to.


Det- 28! 1913 that I last saw her- alive on. and that death occurred, on the date stated above, at." (z.


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


.


Cento ericardolos


(Duration)


TOS ...


ds.


Contributory


(SECONDARY)


(Duration)


mos. . ds.


yrs. .


(Signed) .


Charles Levels,


, M.D.


rt 30


,1915


(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.


mos.


ds.


Where was disease contracted,


If not at place of death ?


Former or usual residence ..


19 PLACE OF BURIAL OR REMOVAL Willau


DATE OF BURIAL


1


~. 191


ADDRESS


20 UNDERTAKER


Ca 123 Emmeri


Winthrop


(City or town.)


1 PLACE OF DEATH


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


15Bales


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


white


female


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


(Month)


(Day)


7 AGE


75


10


mos.


12.


·ds.


yrs.


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).


11 BIRTHPLACE


OF FATHER


12 MAIDEN NAME


OF MOTHER


amelia Colly


PARENTS


1ª BIRTHPLACE


OF MOTHER


(State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Shan R Benmoi


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.


(Address)


Filed


191


N. b. Every fem of information should be partially supplied. Aus should be stated LAUTET. divino Should Statt


(State or country)


Boston Mass


manuel


(Year)


If LESS than


I day, .. .. hrs.


or ...... .min. ?


9 BIRTHPLACE


(State or country)


Hohlunglon U.H.


10 NAME OF


FATHER


Joseph Fiennes


Hoplenglan 4.1+,


REGISTRAR


In the


3


6 DATE OF BIRTH


Lec


17


18,37


17


Oct . 21, 1


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: C'erebro-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 childbirthi or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


7


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.


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1913.


CITY OF BOSTON.


FULL NAME CLARENCE H. PIKE


Place of Death l


Boston


and Residence S


Date of Death


OCT.30


1913.


Age


50


years


months days.


STATISTICAL DETAILS.


SEX.


COLOR


SINGLE, MARRIED, WID., DIV.


M


W


MAR.


Maiden Name


Husband's Name


( EAST ) BOSTON


Birthplace


Name of Father


CHARLES P.PIKE


Birthplace of Father


ENGLAND


Maiden Name of Mother


NORAH S. BEHAN


Birthplace of Mother


IRELAND


BOOK-KEEPER


Occupation


Informant


PHYSICIAN'S CERTIFICATE.


1913, I HEREBY CERTIFY that I attended deceased during last illness, 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 :


ISTRAR'S


-SICUT P


CIVITA DOSTONIA CONDITAAL


2. 1829


OF A BOAT


Contributory . Į (Duration ) 1


G. B.MAGRATH MED. EX.


(Signed)


OCT . 30


1913


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


Place of Burial or removal


DORCHESTER ( OLD )


Undertaker


T.J. LANE


Usual Residence


WINTHROP (75 WASHINGTON


AV)


Filed


NOV. 3


1913


A true copy .


Attest :


EMMYlenen


Registrar.


CITY RE


T PAT 2186S. SIT DEL Primary ( Duration) OFFICE


IMMERSION WITH RESULTING EX-


HAUSTION - ACCIDENTAL CAPSIZING


1850. REGIMINE DONATA A BOSTON. MASS


Registered No.


9788


BOSTON HARBOR - NEAR SPECTACLE ISLAND


Det . 30 , 1913


-


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Wiechat


(No.


64 Wincheck


St. :..


Ward)


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


2 FULL NAME


Sarah. Perfis Young


[If married or divoreed woman or widow give maiden name, also name of husband.] @RESIDENCE 64 Wochen d'h


Saidden Lade


wina Registered NO.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


female


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Singer


6 DATE OF BIRTH


Dec


(Month)


(Day)


13


18,32


(Year)


7 AGE


If LESS than


[ day .......


hrs.


80° yrs.


9 mos. 20


.. .. 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).


School Teacher


9 BIRTHPLACE


(State or country)


Sunafica n. H.


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Sunafec n.1+


12 MAIDEN NAME


OF MOTHER


Sarah. W. Verken.


18 BIRTHPLACE


OF MOTHER


(State or country)


Sunakce Hilf


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informent)


Celino 12,Je ...


(Address)


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


LANOV


(Month)


6


1913.


(Year)


(Day)


17


I HEREBY CERTIFY that I attended deceased from


delph 1st


1913


to


nov. 2th


1913


that I last saw het alive on


1913,


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


27 m.


The CAUSE OF DEATH* was as follows :


Carcinoma of left whitney


(Duretion)


1


yrs.


mos.


ds.


Contributory


(SECONDARY)


(Duration)


.... yrs.


. . mos.


ds.


(Signed)


M.D


" 0 8, 9 (Address)


Bencharzo


* If death followed injury or violence the certifieatc 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 neurfort. 11.1+.


DATE OF BURIAL


400 8


30 UNDERTAKER


Ce.R. 1Sammeni


ADDRESS


Filed.


191


(City or town.)


....


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.


10 NAME OF


FATHER


Williami Tommy


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 ro- 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.




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