Town of Winthrop : Record of Deaths 1913-1915, Part 79

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 79


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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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 "Epidemic cercbro-spinal meningitis") ; Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indcfinite) ; Tuber-


culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of ... .. (namo 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 (sceond- 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shoek," "Uracmia," "Weakness," etc., when a definite disease ean be ascertained as the causc. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ete. 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 violenee, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.


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, etc.


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


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


Withrok


( No .


Circuit Road.


Ward)


(City or town.) {If death occurred la a hospital or institution, give its NAME Instead of street and number.]


2FULL NAME


Ronald Howland Ridgway-


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


4 Cucuit Road Wintheof2


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


-


18 DATE OF DEATH


2


1. 1995


:


(Month)


(Day)


(Year)


5 DATE OF BIRTH


8 (Month)


15


19/11


(Year)


7 AGE


3 yra.


mos. ........


17 ds.


or ...... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


(b) General nature of Industry,


business, or establishment


in


which employed (or employer).


17


I HEREBY CERTIFY thatI attended deceased from


fan


,1915


„, to


tam 19h


1915


that I last saw him alive on


19'


1915


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


Lam ..


The CAUSE OF DEATH* was as follows :


Tubercular meningitis


(Duration).


„.yrs ..


mos.


ds .


Contributory. (SECONDARY)


1.


.(Duration)


....... yrs.


.........


... mos.


.......


ds.


(Signed)


Bismetcalf


Feb 32 orderof why the truth And yammer M.D.


19:50


2 ....


(Address)


Wattrop


r


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


R


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


At place


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


mos. ............. da.


In the


Stato ........


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


....


If not at place of death ?


Where was disease contracted,


Former or usual residonce


-


1 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


2-3


191575


......


ADDRESS


Flied -. 191


REGISTRAR


? BIRTHPLACE


(State or country)


ruthway, mars


10 NAME OF


FATHER


Ronald Ridgway


PARENTS


I) BIRTHPLACE


OF FATHER


(State or country)


") Eengland


12 MAIDEN NAME


OF MOTHER


Lillian Atowland


13 BIRTHPLACE


OF MOTHER


(State or country)


Bath Tur.


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Ronald Ridgway


(Address)


5 SINGLE,


MARRIED.


WIDOWED,


OR DIVORCED


(Write the word)


Singles


3 SEX


' COLOR OR RACE


(Day)


If LESS than


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


:


28


:


D UNDERTAKER


W.C. Skagro


-


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, 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 tho 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 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- 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 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 ncoplasms); Mcasles; 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: 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," "Hacmorrhage," "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 scpticaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under tho 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 Winthrop (No. 23 Wave Way ave St. .. Ward)


2 FULL NAME Marquante Marenghi [If married or divorced woman or widow give maiden name, also name of husband!] @RESIDENCE 23, Wave Way are.


PERSONAL AND STATISTICAL PARTICULARS


Married


1915


(Year)


If LESS than


I day,


.hrs.


or min. ?


10 NAME OF


FATHER


Micoles Chelffo


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Salvador marenghi.


(Address)


23 glance Hay ave


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month) 3 .. 1915 ( Year)


(Day)


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


The CAUSE OF DEATH* was as follows :


natural Causes.


Heart disease, organie


(Sund levouratio button)


mos.


ds.


Contributory


(SECONDARY)


(Duration)


.. yrs.


mos. ..


ds.


(Signed)


Lunga Burger Maymaths


..


, M.D.


Jur.6,


19)


(Address).


MEDICAL EXAMINER


11.55 am


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


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


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 Holy Cross am


DATE OF BURIAL


2-7-1915


20 UNDERTAKER


Hh C, f/ aqq2.


ADDRESS


Filed .- , 191


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


2 -


3


(Month)


(Day)


7 AGE


8 OCCUPATION


(a) Trade, profession, or


particular kind of work.


athome


(b) General nature of industry,


business, or establishment in


which employed (or employer)


9 BIRTHPLACE


(State or country)


Italy-


11 BIRTHPLACE


OF FATHER


(State or country)


Italy-


12 MAIDEN NAME


OF MOTHER


Armuts.


PARENTS


1ª BIRTHPLACE


OF MOTHER


Itali


(State or country)


important. See instructions on back of certificate.


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


47


yrs.


mos.


.ds.


6623 Kutting (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 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 examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (o) Foreman, (b) Automobile factory. The inaterial 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.


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," unqualificd, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonaeum, 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: 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," "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. 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 onc supposed to be due to Alcoholism, etc.


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


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 Hospital


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


Harry L. Smith


[If married or divorced woman or widow


give maiden name, also name of busband.]


@RESIDENCE


20 Coral Ave. Winthrop


Registered No.


66


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Marr.


16 DATE OF DEATH


Feb.


1


(Month)


(Day)


(Year)


6 DATE OF BIRTH


April


5.


1.877


(Month)


(Day)


(Year)


7 AGE


If LESS than


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


or ....... min. ?


a OCCUPATION


(a) Trade, profession, or


particular kind of work


Driver


(b) General nature of industry,


business, or establishment


C


which employed (or employer)


Ice Wagon


9 BIRTHPLACE


(State or country)


Lockertville N. S.


10 NAME OF


FATHER


Henry Smith


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Lockhartville , N.S.


12 MAIDEN NAME


OF MOTHER


Florence Scott


·3 BIRTHPLACE


OF MOTHER


(State or country) Unknown


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Mrs. J. Smith


(Address)


inthron


Filed


Fcb. 5.1915


REGISTRAR


I HEREBY CERTIFY that I attended deceased from


Jan.


26. 1915, to.


Feb.


1.


.


191.5.


11


that i last saw h ..... ].m alive on


1


.. 19|5


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


4 Pm


The CAUSE OF DEATH* was as follows :


Peritonitis


(Duration)


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


mos.


9


ds.


Contributory


Ruptured appendix


(SECONDARY)


(Duration)


1


.yrs.


mos.


ds.


(Signed)


J. G. l'cprail


M.D.


Feb. 4. 191.5 (Address)


Chelsea.


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


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


In the


At place


of death.


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


- ds.


Stato ...... .... yrs. ..


.. mos.


ds.


....


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


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL Hortonville, N.S.


DATE OF BURIAL


Fcb. 7. 191.


.. 5


O UNDERTAKER


A. V.


Sanborn,


ADDRESS


Revere .


MEDICAL CERTIFICATE OF DEATH


Iale


191 .... 5.


37


.. yrs.


11 mos.


29


.s.


Tel. 4, 1715


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, Loco- motive engineer, Civil engincer, 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 ('AUSING 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- -1


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, ctc. 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," "Scnile," etc.), "Dropsy,"" Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical 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 dcad, 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 Conmomwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(No ..


14


George


St. :


Ward)


Charles Eldridge Collura 'FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 14 George It Withuch


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


M


4 COLOR OR RACE


5 SINGLE,


MARRIED.


V


WIDOWED,


OR DIVORCED


(Write the word)


ed.


$ DATE OF BIRTH


8 (Month)


(Day)


7 AGE


63


.yrs.


6 mos.


28 de


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


a OCCUPATION


(a) Trade, profession, or


particular kind of work .....


Ticket a gut


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


9 BIRTHPLACE


(State or country}


20. Eastham Wars


PARENTS


12 MAIDEN NAME


OF MOTHER


Louise Horton


18 BIRTHPLACE


OF MOTHER


(State or country)


30 Earthaun


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Lidice a Colheres


(Address) In songs St.


Filed.


191


REGISTRAR


18 DATE OF DEATH


2


6. 19/37


(Month)


(Day)


(Year)


8


831


17


! HEREBY CERTIFY that I attended deceased from


(Year)


Daquy 29, 1915, to


Felly 6


1915


If LESS than


I day ........ hrst that I last saw hme alive on


Fely'5


1915


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


9º am.


The CAUSE OF DEATH* was as follows :


Cerebral Lowcarbage


(Duration)


X


.yra.


da.


Contributory.


arterio sclerosia


(SECONDARY)


Several(Duration)


yrs.


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


(Signed)


Queviele & Johnson.


M.D.


1915 (Addres).


* 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.


da.


Stato ............ y.s.


In the


... mos.


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


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


Former or usual residenca.


1 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


2-9


1916


D UNDERTAKER


H.C. Skaggs


ADDRESS


Wircheck


(City or town.)


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


Registered No.


Man


10 NAME OF


FATHER


Thomas Callers


11 BIRTHPLACE


·OF FATHER


(State or country)


Boston


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, 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- kcepers 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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