USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 101
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.. m. The CAUSE OF DEATH* was as follows :
acute neplinitis
(duration)
yrs.
mos ...
5
ds.
CONTRIBUTORY
Testes. Broncho- presencia.
(SECONDARY)
(duration)
1
yrs ....
mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
Ww . Date of.
Was there an autopsy ?
-
What test confirmed diagnosis ?
Edward Framger.
(Signed)
4/19, 191 (Address)
49 Bouthelt Road
[].D.
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional spaee.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
4/20
20 UNDERTAKER
ADDRESS
of certificate.
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
Vouchert (City or town)
State.
Registered No.
or
(Usual place of abode)
Length of residence in city or towo where death occurred
years
2
v months
days. 21
How loog in U. S., if of foreigo birth ?
years
[Approved by U. S. Census and American Public Health Association]
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, Compos- itor, Architect, Locomotive 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) Salcsman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial 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 Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- eifically 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 indi- cated 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: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopncumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, 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 (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toins or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"""Debility" ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc.' State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine 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." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Casas for the Medical Examiners. - Under the provi- sions 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, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or onc supposed to bc due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
R 15. 1-'18. 100,000.
15 important. Seo instructions on back of certificato. CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is vory M. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state PARENTS
1 PLACE OF DEATH
County
Post Hospital.
Fort Banka Maso.
Township
or
Village
or
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH massachusetts
State of
Registered No.
[If death occurred In a hospital or institution, give its NAME Instead of street and number.j
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
mate
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( If'rite the word)
Single
6 DATE OF BIRTH
October
( Month)
4
(Day)
1892
1715
(Year)
7 AGE
18
yrs.
6-
mos.
14
ds.
If LESS than
1 day, ____ hrs.
or ____. min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Soldier
(b) Gencral nature of Industry,
business, or establishment in
which employed (or employer)
U. S. army
9 BIRTHPLACE
(State or country)
is LEbastante arke
10 NAME OF
FATHER
Samuel Williams
11 BIRTHPLACE
OF FATHER
(State or country)
Unknown
12 MAIDEN NAME
OF MOTHER
6
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
E.B. Nods Kuin
(Address)
Filed
191
REGISTRAR
16 DATE OF DEATH
april
( Month)
18 1918 ( Day) ( Year)
17
I HEREBY CERTIFY, That I attended deceased from
april 7
8, to
amil 18
191
that I last saw h WL alive on
april 18
8
and that death occurred, on the date stated above, at
8.35/m
191
The CAUSE OF DEATH * was as follows: Cerebro Spinal Meningitis
(Duration) _____ yrs. ________ mos. . //
Contributory .: (SECONDARY)
(Duration )
-
, yrs. ......
.-___ mos ..
ds.
(Signed)
Edward 13 I poderino
M. D.
april 19
, 191-& (Address)
I. M. R. C. Sont Baust. Mars
* State the DISEASE CAUSING DEATH, or, iu deaths from VIOLENT CAUSES, stato (1) MEANS OF INJURY ; and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS)
At place in the
of death
yrs.
mos.
ds. State
yrs.
ros.
ds.
Where was disease contracted, if not at place of death ?
Former or
usual residence.
greenwood, arkansas
19 PLACE OF BURIAL OR REMOVAL Greenwood Arkansas.
DATE CE BURIAL
4, 24
19182
20 UNDERT AKER le Rigenera
ADDRESS
11 -- 3184
(No. Loyd Franklin Williams
St .;
Ward)
City
2 FULL NAME
ADVISED UNIIDU DIALED DIANDARU GONIIFIVALD VE ULATU [Approved by U. S. Census aud American Public Health Association]
Statement of occupation .- Precise statement of occupation 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, c. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial 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 Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Serrant, 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUS- ING DEATHI (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualified, is indefi- nite); Tuberculosis of lungs, meninges, peritonaeum, etc., Car- cinoma, Sarcoma, etc., of . (name origin; “Can- cer" is less definite; avoid use of " Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The con- tributory (secondary or intercurrent) affection need not be stated unless important. Example : Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 da. Never report mere symptoms or terminal condi- tions, such as "Asthenia," "Anaemia" (merely symptom-
atic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital." "Senile," etc.), "Dropsy," "Exhaustion," "IIeart failure," "Haemorrhage," "Inani- tion," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascer- tained as the cause. Always qualify all diseases result- ing from childbirth or miscarriage, as "PUERPERAL septi- chacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, 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." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
NOTE .- Individual offices may add to above list of undesirable terms and refuse to accept certificates containing them. Thus the form in use in New York City states: "Certificates will be returned for additional information which give any of the following diseases, without explanation, as the solo cause of death: Abortion, cellulitis, childbirth, convulsions, haemorrhage, gangrene, gastritis, erysipelas, meningitis, miscarriage, necrosis, peritonitis, phlebitis, pyaemia, septichaemia, tetanus." But general adoption of the minimum list suggested will work vast improvement, and its scope can be extended at a later date.
11-3184
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See Instructions on back of certificate.
769
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Metchips Salute (No.
1
Wanted It
St. :................ Ward)
Hanthoch Man. (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
2-icomene Piscino
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 46 Breed Street
( Widow) 7 cc0000
Husband of Piccolo
....
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX female
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
widowEx
" DATE OF BIRTH
mar
(Month)
if
(Day)
1844
(Year)
7 AGE
If LESS than
I day ......... hrs.
or ... „min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Louse
(b) General nature of Industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Turas + Halis
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Teurasi taly
12 MAIDEN NAME
OF MOTHER
envie Piccolo
18 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
1
(Address)
16
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
V/prix
(Month)
20, 1918
....
(Day)
(Year)
17 HEREBY CERTIFY that I attended deceased from Anil 11 1918 to Atvil 20, 1915 that I last saw h .......... alive on Atiniz 20, 198 and that death occurred, on the date stated above, at 12pm. The CAUSE OF DEATH* was as follows :
.(Duration)
1
... yrs. .............. mos.
ds.
Contributory Diabetes Mellitus
(SECONDARY)
.(Duration)
15 yrs.
mos. ............ ds. «
A
(Signed)
......
..
M.D.
Anillo, 1915 (Address) 34 Patatine PT
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
16 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
.y
10 de.
In the
State ............ yrs. ............ mos. .......... ds .............. Where was disease contracted, If not at place of death ?... Former or
usual residence ..... 446 Pariet Ft Idostar
19 PLACE OF BURIAL OR REMOVAL DATE OF BURIAL
Herby Ceros akill ??
8
20 UNDERTAKER Ce, M, Jobin, 666 Marslow
Leftit ! !
10 NAME OF
FATHER
houph Vere
14 yrs. 1 mos. 16 ds. ...
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. g., Farmer or Planter, Physician, Compositor, Architeet, 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 DEATHI, 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," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- eoma, etc., of .... ........ ........ (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie valvular heart disease; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced 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 ascertaincd as the cause. Always qualify all discases 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Place of
Fort Banks, Winthrop mass
Date of Į april 20
Death *
S
Residence
Liviaunater Ochosi
Age
.years. 45
.. months. .... .days
STATISTICAL DETAILS
SEX
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
2
BIRTHPLACE #
NAME OF
FATHER
7
BIRTHPLACE OF FATHER+
MAIDEN NAME OF MOTHER
5
BIRTHPLACE OF MOTHER # 5
OCCUPATION Pronto m 3 CF /3 ch 1/89
INFORMANT §
PLACE OF BURIAL OR REMOVAL I
DATE OF, BURIAL
4/2.1
190
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Just 26 1908 to. apr 20 1968, 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 : Primary : nephritis interstitial. asterio- sclerosis
(DURATION). .. DAY8
Contributory :
(DURATION) . DAYS
(Signed)
A 2/ 1998 (Address)
First Banks, Mass
SPECIAL INFORMATION only for Hospitals, Institutlons, Translents, or Recent Residents.
How long at
Place of Death ?
. years.
1
months.
25
days
Where was disease contracted,
If not at place of death ?
Filed
190
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
# State or country ; also city, town or county, If known.
§ Name and address of person giving statistical detalls. Il Name of cemetery.
UNDERTAKER CR. Gennem
Registered No ..
Death
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County
Suffolk
State
Lars .
Registered No.
City
Winthrop
No.
St.,
Ward
(If death occurred in a hospital or institution, give its NAMIE instead of street and number)
2 FULL NAME
Gary E.ealty
(a) Residence.
No.
16 Vine Ave.
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female
hite
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of John H . Beatty
6 DATE OF BIRTH (month, day, and year)
12-14 - 147
Days
If LESS than I day, ....... hrs. or ........ min.
8 OCCUPATION OF DECEASED
At home
(a) Trade, profession, or
particular kind of work
(h) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town).
Jamestown Pa.
10 NAME OF FATHER Andrew I.Smith
11 BIRTHPLACE OF FATHER (eity or town)
(State or country)
Leadville Pa.
12 MAIDEN NAME OF MOTHER
Hastings
13 BIRTHPLACE OF MOTHER (eity or town).
(State or country)
Clairmount
* State the DISEASE CAUSING DEATH, or In deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional spaee.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Stoneham
Cemetery
DATE OF BURIAL
1 -2,1 - 19
(Address)
14 Chester Ave.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) 4-21-115. 19
17 I HEREBY CERTIFY, That I attended deceased from april 17. 1918. to ..
that I last saw
alive on
ativ. 21st
19.1.9.
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows :
Grippa Pneumonia (Broncho)
.
(duration)
.. yrs ...
7
ds.
mos.
CONTRIBUTORY
arteria- sclerosis
(SECONDARY)fueled
(duration)
yrs ..
mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death?
.... Date of ......
Was there an autopsy ?.
What test confirmed diagnosis ?
Clinical
(Signed)
IL Partir
/2, 19/8(Address)
Minttrop.
MI.D.
Informant
Mrs. Sam Rich,
19
20 UNDERTAKER
.C. skagen
ADDRESS
Minthror
Township 7 AGE 72 PARENTS 14 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. 15 Filed N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (State or country)
or
or Village
16
Vine Ave.
St.,
.Ward.
(If non-resident give eity or town and State)
ahr 21th 19.4.5.
Years
Months
[Approved by U. S. Census and American Public Health Association]
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 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, Compos- itor, Architect, Locomotive 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer,"
"Foremnan," "Manager," "Dealer," ete., 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 Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically 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 DEATII, State occupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
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