USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 65
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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 fcver (the only definite synonym 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, peritonacum, etc., Carcinoma, Sar- coma, etc., of ... .. (name origin: "Caneer" 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 eausing 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," cte.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shoek," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the eause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," "PUERPERAL peritonitis," etc. State eause 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 suieidc. The nature of the injury, as fraeture 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, ete.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ete.
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 dcad, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No.
46
nevada
.. St.
......
Ward)
2FULL NAME
Jane
Louise
Gifts
[If married or divorced woman or widow give maiden name, also name of husband.] ...
Har widow of Horace &
@RESIDENCE
46 nevada st Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
I SEX
Female
4 COLOR OR RACE
White
$ SINGLE,
MARRIED,
WIDOWED,
-OR DIVORCED
(Write the word)
Widow
1
(Year)
" AGE
If LESS than
i day ......... hrs.
76
„yrs.
mos.
ds.
Cr ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
no. housewife
(b) General nature of Industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
newnirie leite
PARENTS
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE
OF MOTHER
(State or conntry)
1. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
francis & 4: 002
(Address)
-
Filed
191
REGISTRAR
MA DATE OF DEATH
Sulph
16, 1914
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from Salat. 11, 1914, to Selah. 16 191156 that last saw har alive on Sept. 15, 194 and that death occurred, on the dato stated above, at 109:m. The CAUSE OF DEATH* was as follows :
Cerebral Hemorrhage
Did a surgical operation precede death ?
200 Date
..... ...
.. (Duration)
............. yrs.
mos.
ds.
Contributory ..
Pulmonary Ceding,
(SECONDARY)
(Duration)
... yrs.
.. mos.
das.
(Signed)
M.D.
Sep. 16/101 4 (Address).
Winthrop
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
1ª LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ............ yrs.
mos.
de.
State ......... yrs.
............
In the
mos.
......
Where was disease contracted, If not at place of death ?... Former or usual residence.
NO PLACE OF BURIAL OR REMOVAL It Hor e Bojion
DATE OF BURIAL
9/18/11/1915
* UNDERTAKER &'s waterman& Jour
ADDRESS
2326 anshim, 2020
it Boston
N. B. - Every Item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
U." TV. 2
BOSTON
(City of town.) [If death occurred la a hospital or institution, give its NAME Instead of street and number.]
· DATE OF BIRTH
Lept
-
12
(Month)
(Day)
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.
6
1
10 NAME OF
FATHER
John Hely
[] BIRTHPLACE
OF FATHER
(State or country)
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 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) Groecry; (a) Forcman, (b) Automobile factory. Thic 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 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. 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 Nonc.
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 disease. Examples: Cerebro-spinal fever (the only definite synonym 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, 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 discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection necd not be stated unless ini- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report more symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old agc," "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 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.
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
metaly Hor flat
(No.
Janet Myrtle
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
72 Herman- It Will think
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME insteed of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
детле
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Singer
6 DATE OF BIRTH
-
2000
20 1905
(Month)
(Day)
(Year)
7 AGE 8
10
mos.
26
ds.
„min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer).
$ BIRTHPLACE
(State or country)
Denchot Mais
10 NAME OF
FATHER
Frederik. E.
11 BIRTHPLACE
OF FATHER
(State or country)
PARENTS
12 MAIDEN NAME
OF MOTHER
Tracie Mable Williams
13 BIRTHPLACE
OF MOTHER
(State or conntry)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informent)
(Address)
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sept.
(Month)
(Day)
17/1914
(Year)
17 I HEREBY CERTIFY that I attended deceased from Refat 16, 1914, to
1914.
that I last saw has alive on
Lesaf. 16
and that death occurred, on the date stated above, at ...
10a.m.
The CAUSE OF DEATH* was as follows :
Yaloulay Beach Deleau
Indefiniti
.(Duration)
yrs.
mos.
ds.
Contributory.
articular Rheumatic
(SECONDARY)
(Duration)
2 yrs.
.... mos.
ds.
(Signed)
Dr.J. Parler
M.D.
18%, 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).
At place
of deeth.
.. 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
9/18
4
191
20 UNDERTAKER
té 1 / 2.
ADDRESS
(City or town.)
Registered No.
If LESS than
I day, ........ hrs.
yrs.
Jelivil
ʹ
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) tbe 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, peritoneum, 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 deatlı), 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 " ("Congenitai," "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 ali 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 deatbs 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 vioience, 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
wonthink
# 11 (Dowodów
St. :.
Ward)
[if death occurred fæ a hospital or institution, give its NAME instead of street and number.]
Jane. (Betsy Lich field 1
"FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
widow of Ziba. Walter Litchfield
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
Septem Per
(Month)
(Day)
191.
(Year)
& DATE OF BIRTH
Ому
10
1830
(Month)
(Day)
(Year)
7 AGE
If LESS than
f day ......... hrs.
84
.yrs.
1
mos.
10
ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
at Home
(b) General nature of industry.
business, or establishment in
which employed (or employer).
2
9 BIRTHPLACE
(State or country)
Oschic n.M.
PARENTS
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
le. R. 1 Jeuneson
(Address)
wichist ques
1.
Filed
191
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
Laot 19
to
, 1914
Sept 2.0
1914
that i last saw h-s
alive on
20
1914
and that death occurred, on the date stated above, at
6Pm.
The CAUSE OF DEATH* was as follows :
Cunda
Quatation of Heart-
(Duration)
... yrs.
......
6
ds.
.. mos.
Contributory
(SECONDARY)
(Duration) ....... yrs.
mos.
.......
ds
(Signed)
Passt 23, 1914 (Address).
325 Itruller
* 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
ds.
State ........... yra.
mos.
........... ds ...........
Where was disease contracted, If not at place of death ?.
Former or usual residence
10 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
9/23
191
4
" UNDERTAKER
BR. 13 Eración
ADDRESS
4
2 SEX
Female
COLOR OR RACE
-
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Willow
(City or town.)
10 NAME OF
FATHER
Henry Door
11 BIRTHPLACE
OF FATHER
(State or country)
M.D.
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) Salcs- 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 domestie service for wages, as Servant, Cook, Housemaid, ete. 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- 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 "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, peritonaeum, 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 discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intereurrent) 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-
acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite discase can be asecrtained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State eause 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, ete.
2. Deaths supposedly eaused 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, ete.
4. Deaths under circumstances unknown, as A person found dcad, ete.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH 93 Rue Road (No Wartet Mars
St. ;............ ..... Ward)
[If death occurred le a hospital or institution, give its NAME Instead of street and number.]
$FULL NAME
[If married or divorced woman or widow gire maiden name, also name of busband.] @RESIDENCE
manuel, wife of albert. E. Kingsley
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
ª SEX
4 COLOR OR RACE
Mute
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1º DATE OF DEATH
Sefleretin 25, 1914
(Month)
(Day)
(Year)
6 DATE OF BIRTH
31
1861
(Month)
(Day)
(Year)
7 AGE
€3
.. yrs. 1
mos.
12
If LESS than 1 day: 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)
10 NAME OF
FATHER
PARENTS
12 MAIDEN NAME OF MOTHER
1ª BIRTHPLACE
OF MOTHER
(State or conntry)
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(informant)
(Address)
REGISTRAR
=
I HEREBY CERTIFY that I attended deceased from
191.56. to. Soft 23 1914
......
„hrs. k that i last saw h ..... alive on Self 23. 191. and that death occurred, on the dato stated above, at 10-Pm. The CAUSE OF DEATH* was as follows :
Multiple abdominal
Carcinoma
(Duration)
5 yra. X mos. × de.
Contributory.
(SECONDARY)
X
(Duration)
.yrs.
mos. ds
(Signed)
Se4 24 1914 (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).
At place
In the
of death.
... yrs.
........... mos. .
do.
State
mos.
ds ..............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
" PLACE OF BURIAL OR REMOVAL
Pour Heil UTica
11.
4
DATL OF BURIAL
/2€
191
* UNDERTAKER
ADDRESS
Filed 191
N. B. ~ Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
Blanch, L. Kingsley
(City or town.)
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 certificatc.
11 BIRTHPLACE OF FATHER (State or country)
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, c. g., Farmer or Planter, Physician, Compositor, Architeet, Loeo- 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 occu- pation whatever, write None.
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