USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 6
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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 samo 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 ; Chronie 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," otc., when a definite discase can be ascertained as tho cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicemia," " 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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop .....
(No. 110 Grover Ave.
St. ;................. Ward)
BOSTON
(City or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
2FULL NAME
Olive F. Holmes.
[If married or divorced woman or widow give maiden name, also name of husband.] Olive E.Peaslee widow of Richard
@RESIDENCE
110 Grover Ave.Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
fenale
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
widowod
WIDOWED,
OR DIVORCED
(Write the word)
1ª DATE OF DEATH
Feb 18 1913.
. 191
(Month)
(Day)
(Year)
6 DATE OF BIRTH
Jan 28 1823.
(Month)
(Day)
(Year)
7 AGE
If LESS than
{ day, ........ hrs.
9P
.yrs.
mos. .
21
ds.
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).
17 I HEREBY CERTIFY that I attended deceased from
191.
... , to
191
....
....
.......
that I last saw h
alive on
191
....... .
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
ded Aque
(Duration)
............ yrs.
......... .mos. ds.
Contributory
(SECONDARY)
(Duration)
yrs.
mos.
......
.ds.
(Signed)
Albert B. Laman U.
M.D.
191
(Address).
Wintheok, Marz
* If death followed injury or violence the certificate of death must be made ont 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 Forest Hills.
DATE OF BURIAL
Feb-201-
1913.
16 Filed
191
.......
REGISTRAR ....
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
James Peaslee.
U BIRTHPLACE
OF FATHER
(State or country}
unknown
12 MAIDEN NAME
OF MOTHER
Hepzibah Pressy
13 BIRTHPLACE
OF MOTHER
(State or conntry)
Henniker N.F.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
20 UNDERTAKER
man Jaro
ADDRESS
-
9 BIRTHPLACE
(State or country)
Toston Mass
Feb. 18, 1913
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 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, Sur- coma, etc., of .. (name origin: "Cancer" is less definite; avoid use of " Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," " Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy,"" Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, 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
I PLACE OF DEATH
Winthrop
(No 81 Faun Bar Ave. St. :
Ward)
WINTH HROP BOSTON .....
(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
Bolles
Luther E.
81 Faun Bar Ave. Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Feb.
19
(Month)
(Day)
1913
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Jan
1908
Feb. 17
1913
to.
.,
that I last saw her alive on
Feb 17
193
and that death occurred, on the date stated above, at / 0
m. The CAUSE OF DEATH* was as follows :
Carcinoma of Stomach
(Duration)
.yrs.
.........
.mos.
ds.
Contributory
(SECONDARY)
(Duration)
.yrs.
mos.
......... ds.
(Signed)
E. a. mille
M.D.
Feb. 19, 1913
(Address)
natick masz
.....
* 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.
a.t.
place of death
19 PLACE OF BURIAL OR REMOVAL
Spring Erve Com.
Hartford, Conn.
DATE OF BURIAL
Feb. 22 193
ADDRESS
Filed 191
REGISTRAR
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
R. & P 3 SEX Fimale 7 AGE & OCCUPATION PARENTS 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 particular kind of work
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
Married
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Jan. 23, 1959
(Month)
(Day)
1
(Year)
If LESS than
I day ......... hrs.
54
yrs.
0
mos.
27
ds.
Or ........ min. ?
(a) Trade, profession, or
Housewife
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Hartford, Conn.
10 NAME OF
FATHER
Lucius S.
11 BIRTHPLACE OF FATHER (State or conntry) Hartford, Conn.
12 MAIDEN NAME
OF MOTHER
Ann E. Westcott
13 BIRTHPLACE
OF MOTHER
(State or conntry)
Unknown, Conn.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mi s Katherine B. Bolles
(Address)
674 Walk Hill St . Dor.
Jennie Maria Cowles
20 UNDERTAKER
RE E.F. Sharon
In the
A PERMANENT RECORD.
SI SIHL - XNI ĐNIOVANO HẠM XINIVIJ ALIM
Feb . 19, 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, Architeet, 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-
eulosis of lungs, meninges, peritonaeum, etc , C'arcinoma, Sar- coma, etc., of .. . (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronic valvular heart disease; Chronie 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 septicemia," " 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 Examinors:
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 disablod 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
20 metros
(No.
26 Jours-S2
St. : Ward)
[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
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)
16 DATE OF DEATH
24
1913
(Month)
(Day)
(Year)
6 DATE OF BIRTH
24
19/3
17
I HEREBY CERTIFY that I attended deceased from
(Month)
(Day)
(Year)
7 AGE
If LESS than I day ......... hrs.
... yrs.
24.
mos.
1918
... min. ?
8 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)
Winchesmass
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Blomington Ml
12 MAIDEN NAME
OF MOTHER
Mand. L Krall
13 BIRTHPLACE
OF MOTHER
(State or country)
Framingen -. n.H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Robert. E. Bowman
(Address)
26 Jouent St Wuthat have
16 Filed
191
REGISTRAR
Fel 24
, 1913, to.
191
.....
that I last saw h.
......
alive on
. 191
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Still-barn, delayed
delivery due to reach
presentation.
.. (Duration)
Statt You Breach
.. mos.
ds.
Contributory
(SECONDA
presentation
(Duration) .......
mos. ds.
(Signed)
M.D.
Fet 25, 1913 (Address)
224 Huntela To Boston
* 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. ........
ds.
State
......
mos.
ds.
... yrs.
Where was disease contracted, if not at place of death ?. Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
2/26
191.3.
20 UNDERTAKER
let Bennison.
ADDRESS
written mass
Bowoman = Da Boa
(City or town.)
10 NAME OF
FATHER
RotuA. S. Bowmans
I et . 24,
-
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.
aHoo3H LN3NVWH3d V SI SIHL -XNI 9NOVANA HLM AINIVT 3LINA
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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 Winthrop (No. 45, Shirley St. :.. ...... Ward) ...
Winthrop (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
FULL NAME alexander J. P. Machadden [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 45 Shirley St.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
white
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH H Seft 18
1868
(Month)
(Day)
I
(Year)
7 AGE
If LESS than I day ......... hrs.
5ª
mos.
6
ds.
Or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Panche
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
hout Sidney,
Cape Breton
PARENTS
12 MAIDEN NAME
OF MOTHER
annie Eliza Leurs
13 BIRTHPLACE OF MOTHER (State or country)
Cafe 13reload 4.5.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Char R. Bensin
(Address)
18
Filed. ., 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
24, 1913
(Dayf)
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
Exhaustion presumably
Consequent a
the
ora
Jaliohal
(Duration)
.yrs.
mos.
ds.
Contributor Sudden death)
(SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
Sing Burgers magsat)
M.D.
2.20P
(Address).
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
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
DATE OF BURIAL
2/26
191.3 ..
20 UNDERTAKER
ADDRESS
.
10 NAME OF
FATHER
John
11 BIRTHPLACE OF FATHER (Statc or country)
40 yrs.
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 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, (3) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborcr- Coal mine, etc. Womeu 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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