Town of Winthrop : Record of Deaths 1913-1915, Part 62

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 62


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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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-1914.


CITY OF BOSTON.


FULL NAME JOHN G. BRAYMAN


Registered No.


7115


Place of Death l


Boston


LONG ISLAND HOS PT.


and Residence S


Date of Death


AUG. I


1914. Age 85


years


months days.


STATISTICAL DETAILS.


SEX.


COLOR.


SINGLE, MARRIED, WID., DIV.


M


Maiden Name


GIS


RAR'S


IT PATRIBES, S


Primary (Duration)


CITY


FICE


ARTERIOSCLEROSIS


BOSTONIA


Name of Father


BRAYMAN


B


OSTO


N. MASS.


Contributory . } ( Duration) 1


Maiden Name of Mother


-


Birthplace of Mother


PRINTER


Occupation


Informant


Place of Burial or removal


MT. HOPE


Usual Residence


WINTHROP (3 STURGIS ST. )


Filed


AUG. 4 1914.


A true copy.


Attest :


EumSeinen


Registrar.


O


Undertaker


K. T . GOOD


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


from 1914, 1914, 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 :


Husband's Name


R


SICUT P


R. I.


Birthplace


CIVITATISR


CONJITAA.


G MINE DONATA A.


(Signed)


C. G. RICHARDS


M.D.


AUG. I 1914


SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recen! Residents.


A. 1822


Birthplace of Father


CHR. MYOCARDITIS


0 1 1914


1


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


Chelsea


Mass ..


(No.


Frost Hospt.


.......


St. : ...... Ward)


CHELSEA (City or town.)


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


2 FULL NAME


Edward Perry Kenney


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


35 Corel Ave., Winthrop. ass,


PERSONAL AND STATISTICAL PARTICULARS


: SEX


' COLOR OR RACE


6 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Marr.


16 DATE OF DEATH


............


Augr


(Month)


2


, 191.4


(Day)


(Year)


6 DATE OF BIRTH


(Month)


(Day)


7 AGE


50 yrs. 3


mos.


11. ds.


„min. ?


$ OCCUPATION


(a) Trade, profession, or


particular kind of work


Teamster


(b) General nature of industry.


business, or establishment


which employed (or employer).


9 BIRTHPLACE


(State or country)


Portland, Me.


(Duration)


......... yrs.


mos.


1


ds.


Contributory.


(SECONDARY)


(Duration)


....... yrs. ..


......... mos.


ds.


(Signed)


F. J. Powers


M.D.


Ang. ......


3.


.. 1914 (Address).


22] Shurtleff


* If death followed injury or violence the certificate of death ninst be made ont 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 Winthrop Com.


DATE OF BURIAL


Aug . 5 ., 191


(Address)


35 Coral Ave.


Filed Aug. 3, 1914-


REGISTRAR


* UNDERTAKER Charles R. Bennison


ADDRESS


Winthrop


10 NAME OF


FATHER


Perry Kenney


PARENTS


11 BIRTHPLACE


OF FATHER


(State or conntry)


England


12 MAIDEN NAME


OF MOTHER


Louisa Sherlock


11 BIRTHPLACE


OF MOTHER


(State or country)


Eng lend


16 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Wary C. Kenney


Registered No.


514


MEDICAL CERTIFICATE OF DEATH


M


22


1864


17


I HEREBY CERTIFY that I attended deceased from


(Year)


Aug ..


2 ............. , 191.4 ... , to


191-


-


........


If LESS than


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


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 : Cerebral ..... Hemorrhage


In the


4 hrs.


Rug. ʼ


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, e. 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 linc 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 dutics 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," 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 discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report merc symptoms or te minal 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," "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 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 duc to Alcoholism, etc.


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


NORTH


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE/OF DEATH Winthrop (No 90 Birch Road


St. ;


Ward)


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


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Male


+ COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Fugle


6 DATE OF BIRTH


13


1914


17


(Month)


(Day)


(Year)


7 AGE Still Bom


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


yrs.


mos. ds.


or min. ?


8 OCCUPATION


(a)' Trade, profession, or


particular kind of work


7


(b) General nature of industry,


business, or establishment in


which employed (or employer).


9 BIRTHPLACE


(State or country)


"Winthrop, il ass.


PARENTS


11 BIRTHPLACE OF FATHER (State or country) Гурасиел Л.С.


12 MAIDEN NAME OF MOTHER Olace Eher Morin


13 BIRTHPLACE OF MOTHER (State or country) Boston


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


lehar L. Lakeland


(Address)


Winsthhah


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month)


(Day)


, 19101.


(Year)


I HEREBY CERTIFY that I attended deceased from


, 1914 .. , to


., 19192.,


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 :


(Duration)


yrs.


...


mos.


ds.


Contributory


(SECONDARY)


(Duration)


.yrs.


mos. .


ds


(Signed)


..... , 191


(Address)


* If death followed Injury or vlolenee 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


In the


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


usg 8. 191h


20 UNDERTAKER


ADDRESS


Temin


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.


Baby.


Copeland


'FULL NAME [If married or divorced woman or widow give maiden name, also name of husband. @RESIDENCE 90 /Bunch


Good Whetherof


Registered No.


Filed 191


10 NAME OF


FATHER


Chas & Copeland


..


, M.D.


ang


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 minc, 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, peritoneum, etc., Careinoma, Sar- roma, 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 in- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " All- 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 onc 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.


11 BIRTHPLACE OF FATHER (State or country)


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)


14


Filed. , 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH ang 21 (Day)


(Month)


191. (Year)


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


The CAUSE OF DEATH* was as follows : natural Causes; Presumably heart disease and antino Schuur. (Surdicion durantea )


mos. ds.


Contributory. (SECONDARY)


(Duration) ... yrs.


.. mos. ds.


(Signed)


Jerzy Bugen Magath,


M.D.


guy 21 . (Address) MEDICAL EXAMINER


* State the DISEASE CAUSING DEATII, 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.


.. mos.


.....


ds.


State .. .


.. yrs. ....


. . mos. .


...


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


Former or usual residence ..


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


191.


20 UNDERTAKER


ADDRESS


.


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Winthrop (No. Revere


( Jourshad)


2 FULL NAME ..


Patrick & Carry


[If married or divorced woman or widow give maiden name, also name of husband.]s @RESIDENCE 391 Shirts St


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


+ COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


1850


6 DATE OF BIRTH


6


(Month)


(Day)


(Year)


If LESS than I day, . hrs.


63 yr. ...


7 mos. 25 ds.


or min. ?


(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) toland.


3 SEX 7 AGE 8 OCCUPATION PARENTS WHITE PLAINLY, WITH UNFADING INA THIS IS A PERMANENT NEUUND. 1 10 NAME OF FATHER


The Commonwealth of Massachusetts


6287 Winthing (City or tow


St. ....... . Ward)


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


In the


ds ....


ang 21/11/4


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, 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," ete., 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 oceu- 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 synonyni is "Epidemie 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 neoplasms) ; Mcasles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced 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," ete. 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 carbolic 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. Deathis 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.


3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the word) 6 DATE OF BIRTH 10 (Month) (Day) 7 AGE 73 10 yrs. .mos. 6 ds. 8 OCCUPATION (a) Trade; profession, or particular kind of work Retired (b) General nature of industry, business, or establishment in which employed (or employer) 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (State or country) I? MAIDEN NAME OF MOTHER PARENTS WATTE FLAINET, WITH UNTADING INA THIS IS A PERMANENT NEUUND. 9 BIRTHPLACE (State or country) bankin mue


Lunaud M Fil


du. me


leallein l.ray


1ª BIRTHPLACE OF MOTHER (State or country)


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Bensin P dish


( Address)


25 marchell Il


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


1


22


(Month)


(Day)


191 (Year)


I HEREBY CERTIFY that I have investigated the


death of the deceased.


The CAUSE OF DEATH* was as follows ?


Fractured humerus (2 weeks) accidental fall.


(Duration)


yrşı


mos. ds.


Contributory (SECONDARY)


.mos. ds.


(Signed)


M.D.


191 ... (Address)


MEDICAL EXAMINER


* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSE. state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.


.8 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OF 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


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


Glenwerd born Quy 25- 191 !!


UNDERTAKER


MODRESS


296 mocidin Sl


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH theofe (No. 2v- Marshall,


St. ; luttuop ,


Ward)


Derty P. Fish


2 FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 20 marshall H


PERSONAL AND STATISTICAL PARTICULARS


15-


(Year)


If LESS than I day, hrs.


or ...


... min. ?


Fi -d 191


(City or town.)


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


Registered No.


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthifulness 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, ctc. 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 laborcr, 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 eausation), 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 indefinitc); Tuber




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