Town of Winthrop : Record of Deaths 1913-1915, Part 93

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 93


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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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 circunstances 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


Winthrop


(No ..


26


Pleasant


St.


.


.Ward)


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


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


$ SEX


Uff


' COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


3


(Day)


(Year)


7 AGE


If LESS than


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


67 yrs.


8 mos.


10 ds.


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


* OCCUPATION


(.) Trade, profession, or


particular kind of work.


(b) Genaral nature of industry,


business, or establishment


which employed (or employer)


· BIRTHPLACE


(State or country)


Dearfre N.H.


PARENTS


12 MAIDEN NAME


OF MOTHER


Nancy hout nut


18 BIRTHPLACE


OF MOTHER


(State or country)


n.H.


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)(


U.S. Hart.


(Address)


26 Pheasant St


REGISTRAR


16 DATE OF DEATH


1847


17


I HEREBY CERTIFY that I attended deceased from


For fact Gear


191


that I last saw h w alive on


aful 12


1915


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


630


o.m.


The CAUSE OF DEATH* was as follows : Heyfee Withroma, aim above Elliot affected, amputation at Shoulder joint, Cerebral Lassen about ayear ... yrs.


(Duration) mos. ds.


Contributory


(SECONDARY)


(Duration)


- yrs ........


mos.


ds.


(Signed)


W. a. Monson


M.D.


april 14


1915


(Address).


80 Princetar sti


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


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


In the


Åt place


of death ..


yrs.


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


ds.


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


mos.


.......


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


Former or usual residence


1º PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


4.16


.... .


1915


" UNDERTAKER W.C. Shuyqu


ADDRESS


Filed 191


% FULL NAME


Harriet E. Horst.


Hanson- adolphus & Hoyt.


[If married or divorced woman or widow give maiden name, also name of busband.] @RESIDENCE 26 Pleasant St. Withro


Registered No.


(Month)


19- 1916


(Day)


(Year)


· DATE OF BIRTH


8


(Month)


10 NAME OF


FATHER


E rustico Hanson.


11 BIRTHPLACE


OF FATHER


(State or country)


n. H.


apr. 12. 1915


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 engincer, 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," "Dcaler," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retircd, 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 mcre 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, ctc.


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


12 .......


(No


Nevada


St. : .... Ward)


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


2 FULL NAME


Jake


Brutton


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


12 Nevada St


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


Male


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


16 DATE OF DEATH


April


(Month)


14/ 05


(Bay)


(Year)


$ DATE OF BIRTH


abril


(Month)


(Day)


12


12/5/17


(Year)


7 AGE


If LESS than


1 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).


9 BIRTHPLACE


(State or country)


Winthrop


.


10 NAME OF


FATHER


Salomon Brittan


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


England


12 MAIDEN NAME


OF MOTHER


Berna


Sarfati


18 BIRTHPLACE


OF MOTHER


(State or country)


Baston Mass


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


16 Nevada 88


16


Filed .. 191


REGISTRAR


I HEREBY CERTIFY that I attended deceased from 1915 ..... to.


that I last saw him alive on 195 and that death occurred, on the date stated above, at. ... m. The CAUSE OF DEATH* was as follows :


Remature


Birth


Dad a surgical operation precede death


Date


.(Duration)


......


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


mos.


dı.


Contributory


(SECONDARY)


mos. ............. .dı.


Henry


.(Duration)


...


Jelen


M.D.


093 Workingt. car


........


* 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 .............


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


Former or usual residence ..


IS PLACE OF BURIAL OR REMOVAL


ADATE OF BURIAL


Manuale what amil años


10 UNDERTAKER


ADDRESS Waren Salomon 24 Columbiad


...


(Signed)


ajun 15th


195


(Address)


In the


Sanjate


........... yrs. mos. 2 ds.


apr. 14, 1110


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 employinents, 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 (retircd, 6 yrs.). For persons who have no occu- pation whatever, write None.


Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of. .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; 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," "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 dend, etc.


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1915.


CITY OF BOSTON.


MARY KILEY


FULL NAME


Place of Death


Boston


and Residence


Date of Death


APR. 15


1915.


Age


38


years


months days.


STATISTICAL DETAILS.


SEX.


COLOR


SINGLE, MARRIED, WID., DIV.


F


MAR


Maiden Name


BRENNAN


EGIST


RAR'S


Husband's Name


CHARLES KILEY


BOSTON


Birthplace


Name of Father


NEAL BRENNAN


Birthplace of Father


IRELAND


Contributory . (Duration)


(Signed)


J. P. BILL M.D.


APR. 15 1915


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


Place of Burial or removal


MALDEN ( HOLY CROSS)


WINTHROP( 28 THORNTON ST)


Usual Residence


Filed


APR.22 1915


Undertaker


T.F. CALLAHAN


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


from


1915, to


1915, 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 :


JT PATRIBUS, SIT D.


. Primary! ( Duration2) 15


OFFICE


MALIGNANT ENDOCARDITIS


CTVTTAT


BOSTONIA


A). 1822


STO 1130. 8 SREUMMINE DONATA A. N. MASS


Maiden Name of Mother


ELEANOR BARR


Birthplace of Mother


IRELAND


Occupation


CLERK


Informant


CARNEY HOSPT.


Registered No.


3889


A true copy.


Attost :


Emblemen


Registrar.


CITY RE


5 apr. 15, 1915


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


PLAC OF DEATH Anthrop ... (No. 69 Cottage


.. 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


3 SEX


Female Mité


' COLOR OR RACE


6SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Widowed


$ DATE OF BIRTH


april


1845 17


(Year)


7 AGE


If LESS than


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


70


yrs. .mos.


ds.


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


* OCCUPATION


At Home


(b) General nature of Industry,


business, or establishment In


which employed (or employer) ..


$ BIRTHPLACE


(State or country)


(s) Ireland


10 NAME OF


FATHER


Convari


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


verdad


12 MAIDEN NAME


OF MOTHER


Anknown


18 BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Thomas is NochEN


(Address)


69 Colla ges Ple Rd


Filed


191


REGISTRAR


myruditis


.


(Duration)


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


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


ds.


Contributory


(SECONDARY)


(Duration)


.........


.yrs.


mos.


ds.


(Signed)


Charles 7. Mahoney.


M.D. april 18, 1915 (Address) 355 Withlap x


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


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


In the


At place


of death


.yrs.


mos.


ds.


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


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


...... ds ...


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


Former or usual residence


1º PLACE OF BURIAL OR REMOVAL 1


It shows haddeland


Corp.


DATE OF BURIAL


April 2/ 1915


ADDRESS


" UNDERTAKER John J. Ounakey


(Month)


(Day)


(Year)


(Month)


(Day)


10 DATE OF DEATH


april


18 1915 ...


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 69 Cottado tarla Ord. DL


widow of John & Vubec


? FULL NAME


Catharina Con


Conway


Burles


I HEREBY CERTIFY that I attended deceased from UN. 22, 1916, to april 18, 1915. that I last saw he alive on april 17. 1915 and that death occurred, on the date stated above, at5 4 m. The CAUSE OF DEATH was as follows :


(a) Trade, profession, or


particular kind of work


apr. 18, 1915 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 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 occu- pation whatever, write None.


Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-


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 discose; 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," "Hacmorrhage," "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


Menthrone


1


(No ....... 119. Parte ave


St.


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


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


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


ale


4 COLOR OR RACE


Offerte


6 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


1


S


16 DATE OF DEATH


april 18 44


(Month)


(Day)


1913 (Year)


186 17 I HEREBY CERTIFY that I attended deceased from actriceet ........ .


1915, to april 18th 1915. that I last saw humalive on Cfril 18c . 1915. and that death occurred, on the date stated above, at 100m. The CAUSE OF DEATH* was as follows :


Chronic interstitial


Velbrits


.(Duration)


A


............ yrs. -mos. ... ds.


Contributory (SLCONDARY)


ds.


(Signed)


M.D.


Blw. 18°, 195 (Adres).


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


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


In the


At place


of death.


.. yrs ..


.. mos.


ds.


State.


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


........


mos.


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


Where was disease contracted,


If not at place of death ?.


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


1915


1


·O UNDERTAKER


1


ADDRESS


1


. nau quelesa


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


12 MAIDEN NAME OF MOTHER


7


L


1ª BIRTHPLACE OF MOTHER (State or country)


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


Filed


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


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


6 DATE OF BIRTH


(Month)


(Day)


.,


(Year)


7 AGE


If LESS than


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


yra.


mos.


ds.


or ....... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


1


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


9 BIRTHPLACE (State or country)


10 NAME OF


FATHER


11 BIRTHPLACE OF FATHER (State or country}


Villain London


2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 119. Parte Live


... Registered No.


,


1


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when necded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) 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 SP 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 oceupations 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 affeetion with respect to . time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-


culosis of lungs, meninges, peritonacum, etc., Careinoma, 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 ean 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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