USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 93
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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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