Town of Winthrop : Record of Deaths 1913-1915, Part 64

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 64


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culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection necd not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mercly 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 provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:


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


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


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


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


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Hinthron


(No.


66 Junmendella


Ward)


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


Stillborn Garry


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


66 Sunnipido Que


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


4 COLOR OR RACE


Malo White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Single


(Month)


(Day)


(Year)


6 DATE OF BIRTH


Aug


(Month)


29


(Day)


(Year)


7 AGE


If LESS than { day, ........ hrs.


yrs.


mos.


.. 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).


9 BIRTHPLACE


(State or country)


Rinthuof Mass.


10 NAME OF FATHER


PARENTS


11 BIRTHPLACE OF FATHER (State or country) Irelande


12 MAIDEN NAME OF MØTHER Charlotte Jolande


13 BIRTHPLACE, OF MOTHER (State or country) Liteland.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant).


(Address)


66: Lugnavida de


Filed


191


REGISTRAR


1914 17 I HEREBY CERTIFY that I attended deceased from


191 ___


, to.


.......


191


that | last saw h.


alive on


191


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


m.


The CAUSE OF DEATH* was as follows :


Premature (still for)


(Duration).


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


mos.


ds.


Contributory (SECONDARY)


(Duration).


....


..... yrs.


mos. ds.


(Signed)


M.D.


any 30, 1914 (Address).


355 wochenpsy


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


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


At place


of death.


.. yrs.


mos.


ds.


State


yrs.


In the


mos.


ds.


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


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


la.4 31, 194


20 UNDERTAKER


ADDRESS


N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state


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


16 DATE OF DEATH


ana


29, 1914


aug. - 1, 11/4


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, uot 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.


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


I PLAZE OF DEATH Winthrop


(No 45 Graves Cvc


St. :


Ward)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Male


4 COLOR OP RACE White


6


8 DATE OF BIRTH


(Month)


(Day)


185 3 17


(Year)


If LESS than 1 day, ........ hrs.


7


mos.


ds.


or ..... .min. ?


8 OCCUPATION


Salesman


The CAUSE OF DEATH* was as follows :


(Duration)


yrs.


mos.


3


ds.


Contributory (SECONDARY)


(Duration)


.yrs.


mos.


.Os.


(Signed)


kept


2, 1914 (Address) 3251 With 09


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


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


At place


of death


yrs.


mos.


ds.


State


yrs.


In the


mos.


ds


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


Former or usual residence.


1º PLACE OE BURIAL OR REMOVAL Nordlawn


DATE OF BURIAL


DEpt 3/1914


" UNDERTAKER


Filed 191


......


....


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


191.


4


(Month) (


(Year)


I HEREBY CERTIFY that


attended deceased from


august


.,


0


Sept ,


191


., to


4


that I last saw h . alive on


Sept


191


4


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


77 m.


(a) Trade, profession, or


particular kind of work


Dry Goods


3 BIRTHPLACE


(State or country)


England


PARENTS


Scotland


12 MAIDEN NAME OF MOTHERS Thanfret Hinderlow


13 BIRTHPLACE OF MOTHER (State or country)


England


14 THE ABOVE IS TRUE TO THE BEST OF MAY KNOWLEDGE


(Informant) ...


(Address)


16


James Alfred Nation


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


Derved


MADDIED,


WOWED,


OR DIVORCED


(W/ the word)


18 DATE OF DEATH Sistempa 31 (Day)


7 AGE 62 ... yrs.


(b) General nature of industry,


business, or establishment in


which employed (or employer).


10 NAME OF


FATHER


Jame Sherif Hetcon


11 BIRTHPLACE OF FATHER (State or conntry)


M.D.


ADDRESS .


Hinthrop


1


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tiou 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 malignaut 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.


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


I PLACE OF DEATH


(No.


51


Read


St. :


Ward)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


8 SEX


m


4 COLOR OR RACE


w


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Jungle


16 DATE OF DEATH


Sept.


(Month)


(Day)


1


19121.


(Year)


$ DATE OF BIRTH


8


(Month)


27


(Day)


1914


(Year)


TAGE


If LESS than


i day, ........ hrs.


... yrs. mos.


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


aug. 27


1914, to


Sept. 1.


that f last saw h ._.... alive on


191.46.


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


90m.


The CAUSE OF DEATH* was as follows :


(Duration)


mos. .....


ds.


Contributory


(SECONDARY)


.(Duration)


.yrs. ..


......


mos.


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


ds.


(Signed)


Multand


M.D.


LA-2, 1914 (Address)


118 Primaion


....


* 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).


At place


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


mos. ........


ds.


State


In the


mos.


„ds.


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


Former or usual residence


1º PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


4-2


$91


4


D UNDERTAKER


ADDRESS


Filed. 191


10 NAME OF


FATHER


Raymond Eroch


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


VraiBale Mars


12 MAIDEN NAME


OF MOTHER


Douglas


1ª BIRTHPLACE


OF MOTHER


(State or country)


Winthrop


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Raymond , Coches


(Address)


Si Readst


REGISTRAR


Raymond G. Crocker


2FULL NAME.


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


9 BIRTHPLACE


(State or country)


Wintheok


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 applics 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 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," ctc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ctc. 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- LASE 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 tungs, gs, meninges, pertionalum, coo.


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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite 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 due to Alcoholism, etc.


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


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1914.


CITY OF BOSTON.


8077


Registered No.


Place of Death and Residence S


Boston


Date of Death


SEPT.4


1914.


Age


I


years


8


months


days.


STATISTICAL DETAILS.


SEX.


COLOR.


SINGLE, MARRIED, WID., DIV.


F


W


SIN.


Maiden Name


Husband's Name


WINTHROP


Birthplace


Name of Father


EDWARD W. BERCHTOLD


Birthplace of Father


CLEVELAND. OHIO


Contributory · ? (Duration)


1


Maiden Name of Mother


NELLIE F. SPILLANE


Birthplace of Mother


IRELAND


(Signed)


M.D.


SEPT.4


1914


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


Place of Burial or removal


MALDEN (HOLY CROSS)


C. R. BENNISON


Undertaker


WINTHROP


Usual Residence


WINTHROP ( 16 BILLOW AV)


Filed


SEPT.5 1914.


A true copy.


Attest


ErMSlenen


Registrar.


IS


RAR'


T PATRIEUS


Primary SEPTICEMIA - 17 DYS


ICU (Duration)


OBIS


FFICE


LLAL? BOSTONIA


1.A.1822.


CONDITAAL


S REGIMINE DONATA A 1830.


MASS.


C. H. DUNN


Occupation


Informant


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


from 1914, to 1914, 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 :


CITY


STON


FULL NAME


HELEN BERCHTOLD


ROTCH MEMORIAL HOSPT.


Sept. 4, 1914


-


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


11 BIRTHPLACE OF FATHER (State or country)


Russia


12 MAIDEN NAME OF MOTHER Lemie Frank


BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Harring


Frank


(Address)


Filed . 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Sept


(Month)


594


(Day)


(Year)


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


The CAUSE OF DEATH* was as follows : Incised wounds of the


week, with resulting


haemmage, Suicidal


.(Duration)


.. yrs.


mos.


ds.


Contributory. (SECONDARY)


(Duration)


.. yrs.


mos. ...


.ds.


Sell V. 1914 (Addre


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.


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


At place


of death


yrs.


mos.


In the


ds.


State.


.. yrs.


mos.


ds ...... . ..


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


Former or usual residence


DATE OF BURIAL


10 am Sex 6. 1914


20 UNDERTAKER


Jacob Poyour


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


6319 (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]


Ray


2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 1318 Commonwealth are:


Manyhands ale Silva Emerson


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX Kemal


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Married


6 DATE OF BIRTH


1889 17


(Month)


(Day)


(Year)


7 AGE


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


25 yrs .... mos.


ds.


or min. ?


8 OCCUPATION (a) Trade, profession, or particular kind of work


X


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


9 BIRTHPLACE


(State or country)


Barton Mass


10 NAME OF


FATHER


Lewis Frank


(Signed)


Lunge Burgers Magneto,


M.D.


19 PLACE OF BUNIAL DR REMOVAL Hakfield class 2


ADDRESS


39. Capelan of Du


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


PLACE OF DEATH


( No. 46 Pearl are


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of oceu- 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 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 cxamples: (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 oeeu- pation whatever, write Nonc.




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