Town of Winthrop : Record of Deaths 1913-1915, Part 63

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 63


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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eulosis 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; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second-


ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mcre symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite discase can be ascertaincd as the causc. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," "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 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- posurc, 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, ete.


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


Gardner


(No


Heywood Hospital


St. ;.


Ward)


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


2 FULL NAME


annie Maria (Barnabu) Barnaby


[If married or divorced woman or widow


give maiden name, also name of husband.]


bohum


anton Barnaby M. D.


aRESIDENCE 31 Bartlett Road, Winthrop, Mas Registered No.


168


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


ang. 23


.. 1914


.....


(Month)


(Day)


(Year)


"DATE OF BIRTH


@ ct. 15


(Month)


(Day)


(Year)


" AGE


If LESS than


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


10


.. yrs.


mos.


8


ds.


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


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


none


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


9 BIRTHPLACE


(State or country)


nova Scotia


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Nova Scotia


12 MAIDEN NAME


OF MOTHER


Marietta Dickey


13 BIRTHPLACE


OF MOTHER


(State or country)


nova Scotia


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Marietta Barnaby


(Address)


d Habital


Filed


191


REGISTRAR ....


(Duration)


14


yrs.


mos ..


ds.


Contributory.


arterio Sclerolic changes


(SECONDARY)


unknown


yrs.


(Duration)


.mos. .


ds.


(Signed) M.D.


191 ........ (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.


In the


.. mos.


ds.


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


mos.


ds


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


Former or usual residence


12 PLACE OF BURIAL OR REMOVAL Winchester, Mas ..


DATE OF BURIAL


aug. 26. 1914


20 UNDERTAKER f. M. Smith


ADDRESS


Gardner


.........


IO NAME OF


FATHER


George Eaton Barnaby


1842


17


I HEREBY CERTIFY that I attended deceased from


Cmq. 6


4


191


to


aug. 17


1914


...


that I last saw her alive on.


aug. 17


191


4


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


a.m.


The CAUSE OF DEATH* was as follows :


Diabetes Mellitus


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, irrespectivo of age. For many occupations a singlo 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 ncedcd. 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," "Forcman," "Manager," "Dcaler," 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," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, ctc., of „(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; 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: Mcasles (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," "Uraemia," "Weakness," etc., when a definite discase 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 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


Marithrok


.(No.


40


Cross


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


Dorothy audrey Lane


2FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 40 CrossSt, Nanthrop


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


H


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Single


1914 (Year)


7 AGE


If LESS than


! day ......... hrs.


of ......... 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)


Winthrop


10 NAME OF


FATHER


Frailes Lana


PARENTS


11 BIRTHPLACE


OF FATHER


(Skole or country}


ilistan, West Virginia


12 MAIDEN NAME OF MOTHER


Dolly Ox new


18 BIRTHPLACE


OF MOTHER


(State or country)


nova Scotia


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Mis Lane mother


(Address)


1&


Filed


191


REGISTRAR


17


I HEREBY CERTIFY that I attended deceased from august 11, 191. ., to august 24. 191_2 .. that I last saw hy alive on 191 Quant 24 4 and that death occurred, on the date stated above, at. 2-3 0Pm.


1


The CAUSE OF DEATH* was as follows : Tubercular. Meningitis.


(Duration)


...... yrs. ........... mos. ..


ds.


Contributory.


(SECONDARY)


(Duration)


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


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


ds


(Signed)


M.D.


cinque + 21 1014 (Address)


* 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).


Åt placa


of death ............ yrs.


mos.


ds.


State


In the


mos.


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


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL Cambridge Com


DATE OF BURIAL


augirl


19146


D UNDERTAKER


U V Sanborn


ADDRESS


(City or town.)


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


6 DATE OF BIRTH


Fick


(Month)'


28


(Day)


1ª DATE OF DEATH


(Month)


44


1914


(Day)


(Year)


.yrs.


5


mos.


24 da.


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 cach and every person, irrespective of age. For many occupations a single word or term ou the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, Loco- motive engincer, 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 linc is provided for the latter statement; it should be used only when nccded. 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," "Forcman," "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 houschold 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. Carc 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. -- Namc, first, the DIS- CASE 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, 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 (sccond- 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 merc symptoms or terminal conditions, such as "Asthenia," "An- acmia" (mcrely symptomatic), "Atrophy," "Collapsc," "C'oma," "Convulsions," "Debility" ("Congenital," "Senilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhagc," "Inanition," "Marasmus," "Old agc," "Shock," "Uracmia," "Wcakncss," etc., when a definite discase can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical opcration 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 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


...........


.......


(City or town.)


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


2FULL NAME


Mary


Elizatset


Davis


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


wife of almond. W. Dans


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX female -


4 COLOR OR RACE


White


å SINGLE,


MARRIED,


WIDOWED,


Married


(Write the word)


18 DATE OF DEATH


august


(Month)


(Year)


(Day)


27, 1914


....


6 DATE OF BIRTH


24


185 2


(Month)


(Day)


(Year)


7 AGE 62


.угs. 2


mos. 3 ds.


or ......... min. 7


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


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


Flexure of Intestine


-


(Duration)


30


.yrs. ..


Contributory.


(SECONDARY)


X


.(Duration)


yrs.


mos.


... ds.


(Signed)


Owiele & Johnson


M.D.


Ceny 28. 1914 (Address).


Wwwburgh 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.


In the


da.


Stata


............ yra.


mos.


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


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


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL Winslet mais


DATE OF BURIAL


8/31


191


D UNDERTAKER


ADDRESS


Flied 191


REGISTRAR


17 I HEREBY CERTIFY that I attended deceased from 4 June 50, 1914, to. aug 29 191


If LESS than I day ........ hrs. that i last saw her alive on ang 26 1914 and that death occurred, on the date stated above, at 12-am. The CAUSE OF DEATH* was as follows :


1


Carcinoma of Signiaid


9 BIRTHPLACE


(State or country)


W dysport Coun


10 NAME OF


FATHER


Christian Russ


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


12 MAIDEN NAME


OF MOTHER


Cnn . K. Suy der


13 BIRTHPLACE


OF MOTHER


(State or conntry)


new Jersey .


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


(No.


St. : Ward)


....


1 PLACE OF DEATH


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 cach 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 cngincer, Civil engineer, Stationary fircman, 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) Spinncr, (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 laborcr, 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, Houscwork, 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- DASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. 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 discasc; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need 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," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite discase can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the 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.


important. See instructions on back of certificate. CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ....


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Minttonik


(No.


4%.


Center.


St. : Ward)


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


Johnd. King.


2 FULL NAME ..


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


42 Wo entin S.


.... Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


Male


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Single


16 DATE OF DEATH and 28 . 1914 (Year)


(Month)


(Day)


* DATE OF BIRTH


. April


2,


...


(Month)


(Day)


(Year)


7 AGE


If LESS than ¿ day ........ hrs.


.yrs .....


4


mos.


26


ds.


Or ........ min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work.


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


9 BIRTHPLACE


(State or country)


10 NAME OF


FATHER


Edmund f.


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Shelburn. A.S.


12 MAIDEN NAME


OF MOTHER


Habel . Hooker


13 BIRTHPLACE


OF MOTHER


(State or country)


East Bratin.


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


father


(Address)


42 Center PL


Filed 191


REGISTRAR


I HEREBY CERTIFY that I attended deceased from aug 19 1914, to aug 28 1914 that I last saw him alive on ander 27 195 and that death occurred, on the date stated above, at 6:30A.m. The CAUSE OF DEATH* was as follows : Gastro Enteritis


1


Ceptichiamia Following multiple abcessos Did a surgical operation precede death ? yo Date Om (27 14 small masion in abcess of wrist. .. yrs.


„mos. 9 de.


Contributory


(SECONDARY)


(Duration)


.. yrs,


.. mos. ds.


(Signed)


(315 metral)


M.D.


an 28


1914 (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).


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


29.


191.54


" UNDERTAKER


Richard b. Kirby


ADDRESS 15-17 Jumu


19/4/12


a. LO


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, 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 necded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Forcman, (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 houschold only (not paid House- keepers who reccive 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 rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-




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