Town of Winthrop : Record of Deaths 1913-1915, Part 81

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 81


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- EASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie eerebro-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, cte., 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, ete. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatie), "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 septicacmia," "PUERPERAL peritonitis," ete. 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 Medieal Examiners:


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


2. Deaths supposedly eaused by violenee, 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


(No.


Harry Mckay Broude


rou den


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of hushandĄ


@RESIDENCE


20 Laurel Pack Muchas registered No.


PERSONAL AND STATISTICAL PARTICULARS


(Month)


(Day)


(Year)


If LESS than I dey ......... hrs.


19


yrs.


1


mos.


25.


.ds.


or


min. ?


10 NAME OF


FATHER


Solen I-Brander


14 THE ABOVE IS TRUE TO THE BEST, OF MY KNOWLEDGE


(Address)


Filed .. 191.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


17


I HEREBY CERTIFY that I attended deceased from


76-10"


1915


, to.


76 15


1915


that I last saw him


alive on


Feb- 15


1915


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


6.6m.


The CAUSE OF DEATH* was as follows : Lobar Pneumonia


(Duration)


.. . yrs.


mos.


7


ds.


Contributory (SECONDARY)


(Duration)


BrMetcalf


.yrs.


mos.


ds.


(Signed)


7617. 1915


(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.


mos.


5


ds.


State ...


7 yrs.


mos.


de


Where was disease contracted,


If not at place of death ?.


20 Laurel Pall virtud


usual residence


Former or


20 Lourd Pack


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


Feb 19.


1915


20 UNDERTAKER


6.12.2.


ADDRESS


1


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


1 PLACE OF DEATH


3 SEX


Ihate


7 AGE


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


$ BIRTHPLACE


(State or e


11 BIRTHPLACE


OF FATHER


(State or country)


12 MAIDEN NAME


OF MOTHER


PARENTS


13 BIRTHPLACE


OF MOTHER


(State or country)


(Informent)


CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very


(b) Generel neture of industry,


business, or esteblishment in


which employed (or employer).


important. See instructions on back of certificate.


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


8 DATE OF BIRTH


2000


25 1915


1


1915


(Month)


(Day)


15


(Year)


(City or town.)


Ward)


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


In the


M.D.


Fel. 15, 1915


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 Ilouse- 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 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.


The Conunomwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Winthrop


(No. XXX Guald


St. :.


(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


4 COLOR OR RACE


W


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Single


$ DATE OF BIRTH


10 (Month)


17


(Day)


... , (Year)


7 AGE


If LESS than


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


.. yrs. 3 ...... mos.


....... 29 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)


10 NAME OF


FATHER


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country}


novaScotia


12 MAIDEN NAME


OF MOTHER


Margautima ceachern


18 BIRTHPLACE


OF MOTHER


(State or country)


09. 2


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


author Dalimple


(Address)


Gerald $PM


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


2-


(Month)


(Day) 16 1915- (Year)


I HEREBY CERTIFY that I attended deceased from


Feb 2 00


1915


to


76-16ª


1915


....


that I last saw her


alive on


7616


1915


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


9.00 Am.


The CAUSE OF DEATH* was as follows :


Gastro Interitio


(Duration)


.yrs.


... mos


ds.


Marasmus following severe


Contributory


(SLCONDARY)


returns


3


(Duration)


.. yrs.


mos.


22 ds.


(Signed)


21 metcalf


M.D.


76-17. 1915 (Address)


Winthrop


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


18 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


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


20 UNDERTAKER


W.C. Skaggs


ADDRESS


Filed 191


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.


2 FULL NAME


Mary Frances Daluemple


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


............ Ward)


.


14


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; (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, ete. 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: Furmer (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, 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 necd 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 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.


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 Pinturah .. (No. 287 Shirley St. :


John Fahey


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband,1


@RESIDENCE


1287 Shirley at


PERSONAL AND STATISTICAL PARTICULARS


4 COLOR OR RACE


5 SINGLE,


MARRIED.


WIDOWED,


OR DIVORCED


(Write the word)


Widowed


& DATE OF BIRTH


(Month) (Day)


1


(Year)


7 AGE


64


... yrs.


mos.


. ds.


or ...


min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Laborer


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


' BIRTHPLACE


(State or country)


teland


10 NAME OF


FATHER


Fahey


PARENTS


12 MAIDEN NAME OF MOTHER Unknown.


13 BIRTHPLACE


OF MOTHER


(State or country)


HEland


14 THE ABOVE IS TRUE TO THE BEST OF,MY KNOWLEDGE


(Informant)


,Alfred It Coughlin


(Address)


1287 Shulalol


Filed .. 191 ...


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Tehran


1915


(Month)


(Day)


1915


(Year)


17 HEREBY CERTIFY that I attended deceased from Fel 112 1915. o


Ich 18€


1919.


that I last saw h


alive on


Ich 185.


191.8 ....


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


m.


The CAUSE OF DEATH* was as follows :


nephritis


.(Duretion)


.. yrs.


mos.


18 ds.


Contributory


(SECONDARY)


(Duration) .. yrs.


.. mos.


ds.


Julien


M.D.


093 Washington


* 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.


mos.


ds.


....


In the


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


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL Marlboro Immaculate Conception


DATE OF BURIAL


H


VEV22,


20 UNDERTAKER


John & O Male


ADDRESS


.


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


Ward)


.... . .


Registered No.


3 SEX


Male White


If LESS than


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


0


11 BIRTHPLACE


OF FATHER


(State or country)


ttcland


(Signed)


fch 19th,


....


(Address)


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, 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 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 Examincrs:


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


(No.


(Dodge) Barbara


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


26 En fresa Roal


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


female


4 COLOR OR RACE


White


6 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


1915


(Month)


(Day)


(Year)


7 AGE


If LESS than


| day ......... hrs.


or .....


min. ?


& OCCUPATION


(a) Trade, profession, or


particular kind of work


(b) General nature of industry,


business, or establishment in


which employed (or employer).


2 ---


· BIRTHPLACE


(State or country)


Winstant mess


PARENTS


12 MAIDEN NAME


OF MOTHER


Ivanella. Mi Sembra


18 BIRTHPLACE


OF MOTHER


(State or country)


Concord. Ut


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


Filed 191 ........


REGISTRAR


16 DATE OF DEATH


-


(Month)



(Day)


1914


(Year)


17


I HEREBY CERTIFY that I attended deceased from


Feb 16


1915 to


Job- 19


191


.. .


that I last saw hw alive on


7-6- 19


1915


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


11 / m.


The CAUSE OF DEATH* was as follows : Premature borta six mois.


(Duration)


yrs.


mos.


3


ds.


Contributory (SECONDARY)


(Duration)


..... yrs.


mos.


ds.


(Signed)


M.D.


7/21. 1915 (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.


mos.


3 ds.


State


.yrs.


In the


mos.


ds. 3


Where was disease contracted, If not at place of death ?. Former or usual residence


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


2/2 2


1915


-


ADDRESS


20 UNDERTAKER


e. 12.13.


(City or town.)


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


6 DATE OF BIRTH


16


.yrs.


Y


mos.


3


ds.


2


10 NAME OFI


Unest Leon Dodge


11 BIRTHPLACE


OF FATHER


(State or country)


It Johnson Ut


Fel. . 19 1915


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, 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 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.




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