USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 109
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or Village Metcalf Hospital
St ..
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number )
2 FULL NAME
Frederick Devereux
(If in the Army or Navy of the United States, give rank; organization, etc .. .....
(a) Residence. No. 203 Lincoln St.
St.,
.Ward.
(Usual place of abode)
Length of residence in city or town where death occorred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year) July 3, 1918
7 AGE
Years
Months
Days 7
If LESS than
1 day, ....... hrs.
or ........ min.
8 OCCUPATION CF DECEASED
(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
(duration)
yrs. .. .. . ....
mos.
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
........ yrs ................. mos
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
No
Date of.
Was there an autopsy ?
No
What test confirmed diagnosis ?
V
(Signed)
Edmund F- moram
M.D.
7-11. 1918 (Address)
664 Bermington ST., E. Boston
* State the DISEASE CAUSING DEATH, OY in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
14
Informant
Frederick Devereux
(Address)
209 Lincoln St
15 Filed ,19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) July 10, 1918
17
I HEREBY CERTIFY, That I attended deceased from
July 10
, 1918
to
July 10
,1918.
·
that I last saw ham
alive on
July 10
1918.
and that death occurred, on the date stated above, at
9 00 P. m.
m.
The CAUSE OF DEATH* was as follows :
Premature birth
9 BIRTHPLACE (city or town)
Winthrop
(State or country)
10 NAME OF FATHER Frederick
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Boston
12 MAIDEN NAME OF MOTHER Katherine Murray
13 BIRTHPLACE OF MOTHER (city or townRockland
(State or country)
Mass
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
St. Michaels Boston
DATE OF BURIAL
19
16
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,
or
City
No ..
(If non-resident give city or town and State)
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 linc is provided for the latter statement; it should be used only when nccded. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may forin part of the second statement. Never return "Laborer,"
"Foreman," "Manager,' "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal minc, etc. Women at home, who are engaged in the dutics 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 DEATH, state occupation at beginning of illness. If retired fromn 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 tine and causation), using always the same accepted term for the saine disease. Examples: Cerebrospinal fever (the only definite synonyın is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fcrer (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinitc); 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 necd not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broneho- pneumonia (secondary), 10 ds. Never report mere symnp- toms or terminal conditions, such as "Asthenia," "Anemia" (mcrely symptomatic), "Atrophy," "Col- lapsc," "Coma," "Convulsions,"" "Debility" (“Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite discase can be ascertained as the causc. 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
on statement of cause of death approved by Committee on Nomenelature of the American Medical Association.)
Cases 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 one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
1
R 15. 1-'18. 100,000.
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,
...
(City or town)
Registered No ..
or Village
No.
St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
walter. J. Waw
(a) Residence.
No.
2 ª/3 ates are.
St., .........
.Ward.
(Usual place of abode) /
Lengto of resideoce in city or town where death occurred
years
months
days.
How long io U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Make
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (mouth, day, and year)
7 AGE
49
Ycars
Months
0
Days
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, professioo, or
particular kind of work.
(b) General oature of indostry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Montreal
(State or country)
10 NAME OF FATHER
Canada
John Mac
PARENTS
11 BIRTHPLACE OF FATHER (eity or town)
(State or country)
England
12 MAIDEN NAME OF MOTHER unknown
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
England
14
Informant
Nife
(Address)
15
Filed ., 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) July 11.
19/8.
17
HEREBY CERTIFY, That I attended deceased from
-feely 11th
1918
July 11.
19
18.
to
.
Quelle IL.
19.78.
that I last saw h - alive on
-.....
and that death occurred, on the date stated above, at 9-30%. m. The CAUSE OF DEATH* was as follows :
Cerebral Hemorrhage
(duration)
yrs.
CONTRIBUTORY
Chronic Interst. nephrita
(SECONDARY) Ladek.
(duration)
yrs.
.. mos ...
ds.
18 Where was disease. contracted
if not at place of death?
ar place of devil
Did an operation precede death?
220. Date of
-
Was there an autopsy ?.
200
What test confirmed diagnosis ?
Clinical
(Signed)
MR Partir
7/3, 19/8 (Address)
Manthis, mans.
., M.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 space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
July 13
19/0
20 UNDERTAKER
G.R. Qua
ADDRESS
winchik
of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County.
Suffolk
Township
vinheta
City.
State
muss
or
(If non-resident give city or town and State)
[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, 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 Servant, Cook, Housemaid, cte. 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.
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; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, 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," cte., 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 DEATHIS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Of 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 be 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918. DAVID F.TURNBULL
CITY OF BOSTON
FULL NAME
Place of Death l and Residence
Boston
JULY 12
1918, Age 82
years
6
months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID .. DIV.
M
W
M
Maiden Name
Husband's Name
R
CITY
Name of Father
THOMAS TURNBULL
Birthplace of Father
Maiden Name of Mother
ELIZABETH CHISHOLM
Birthplace of Mother
(Signed)
A.L.KINNE M D.
JULY 12
1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT.2 YRS. +
Place of Burial or removal LONG ISLAND CEM.
Undertaker A.P.MORAN
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness, from 1918, to
1918, 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:
TRAR'Ny PATRIBUS PRESU /H (Duration OOFFICE
ARTERIO-SCLEROSIS.
CHR.CYSTITIS
Birthplace
BOSTON
BRONCHO-PNEUMONIA
CIVITATIS
TA A. 1822
BOSTONIA CONDITAA TSREGIMINE DONATA A BOSTON 1630.
MASS
Contributory: (Duration)
Occupation CARPENTER
Informant
Usual
Residence
WINTHROP
JULY 16
1918.
Filed
A true copy. Attest : ErMSlenen
Registrar.
Registered No.
7162
LONG ISLAND HOSPT.
Date of Death
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop
Chelsea Creek at Hear of 404 RocheSt Ward)
2 FULL NAME James Sherwood Sran [If married or divorced woman or ridow give maiden name, also name of busband.] @RESIDENCE 428 Revere St
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Vingle
6 DATE OF BIRTH
0. 1906
(Month) (Day)
(Year)
7 AGE
12 yrs ..
mos. ds.
or ...
.. min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Student
(b) General nature of industry, business, or establishment in which employed (or employer)
(Duration)
.. yrs.
mos.
ds.
Contributory .........
(SECONDARY)
(Duration)
yrs.
mos. ds.
(Signed)
Lunge Burgos Magnata
M.D.
(Address).
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATHI, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
.. yrs.
mos.
......
ds.
State
.. yrs.
...
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
(Informant)
(Address)
435 Kewellt
16
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
15 1918
(Day)
(Year.
17 1 HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : Downing, accidental .
(Sank while trying to Surin)
9 BIRTHPLACE
(State or country)
Boston mass.
10 NAME OF
FATHER
LEander
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Halifax AsScotia €
12 MAIDEN NAME OF MOTHER beatrice magrattis
in the
mos.
ds
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
DATE OF BURIAL
7/17
1910
"0 UNDERTAKER John J. COMakey
ADDRESS
inclinato
...
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
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.
9844
(City or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
If LESS than
1 day, ........ hrs.
9
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) Forcman, (b) Automobile factory. The inaterial worked on may form part of the second statement. Never return "Laborer," "Foreman," "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 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 domestie 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 (rctired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- KASE CAUSING DEATII (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, cte., Carcinoma, Sar- coma, etc., of .(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; Mcasles; Whooping cough; Chronic valvular hcart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (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," "Ilacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all
diseases resulting from childbirth or miscarriage, as "PUER- PERAL scpticacmia," "PUERPERAL peritonitis," ctc. State eause for which surgical operation was undertaken. For VIOLENT DEATHIS State MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, OF HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."
Cases for the Medical Examniners. - 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, cte.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, cte.
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, ete.
R 16. 10-'17. 10,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County.
Mid.
State
Lor Village.
Township
Cambridge
No.
Middlesex Neto.
St .. ... Ward
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
(a) Residence.
No ...
5. Thornton PAR.
.Ward.
(If non-resident gire city or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
2.
4 COLOR OR RACE
- M
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
)
6 DATE OF BIRTH (month, day, and year)
7 AGE
Ycars
0
Months
0
Days
0
If LESS than
1 day, ....... hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Cambridge
(State or country)
10 NAME OF FATHER
Clarence OP.
PARENTS
11 BIRTHPLACE OF FATHER (city or town).
(State or country) somerville Maco
12 MAIDEN NAME OF MOTHER marina
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Tozune
14
Informant Father
(Address)
15 1/30, 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) 7/15/18 19
17 I HEREBY CERTIFY, That I attended deceased from
19 ..
„, to
19
that I last saw h.
alive on
19
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Congenital Cystic
difence of kidney
(duration)
......
... yr's ..... 00006404
mos.
ds.
CONTRIBUTORY
(SECONDARY)
(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 ?
John F. Smith
(Signed)
M.D.
, 19 (Address)
Doctor
* 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 space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
. Lamb. Cem, Camb 1/16
DATE OF BURIAL
018
ADDRESS
20 UNDERTAKER 8 . Fudge Low Carb.
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,
Cambridge
mass
Registered ~ 1189
City
Hopkins
(Usual place of abodc)
Length of residence in city or town wbere death occurred
years
months
days.
How long in U. S., if of foreign 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, Architeet, 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 necded. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Groecry; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer,"
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