USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 113
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. (duration)
.... yrs.
.mos.
ds.
CONTRIBUTORY
artino televario
(duration) 5 yrs .yrs. ......
.mos.
ds.
18 Where was disease contracted if not at place of death?
Did an operation precede dcath ?
Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
7/25-19/8 (Address) 25 Cuscintar nece
* 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 St mary's newburyport They, 0 19
20 UNDERTAKER
ADDRESS
Township 2 FULL NAME 7 AGE particular kind of work PARENTS Informant of certificate. 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, NV. D. - WRITE PLAINLY, WITHT ONFADING IRK- THIS IS A PERMANENT RECORD. Every item of information should be · (b) Geoeral nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
STANDARD CERTIFICATE OF DEATH
(City or town)
City No.
(If non-resident give city or town and State)
.. , M.D.
M N. B. - WRITE PLAINL'
KI.VISED UNITED STATES STANDARD CERTIFICATE OF PLATH [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) 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, 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 "Epidemie 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- 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- toms 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- inus," "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- P'ERAL 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 suclı, if impossible to de- termine clefinitely. 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.)
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.
.
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
State
mass
(City or town)
Registered No .......
or Village .. No. 175, Main Winthrop
. St.
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
James White
23 years
8 months
15 days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of"
Jeane white Die
If LESS than
1 day, ........ hrs.
or ........ min.
particular kind of work (a) Trade, profession, of Marine Eenginice
12 MAIDEN NAME OF MOTHER Black.
13 BIRTHPLACE OF MOTHER (city or town) (State or country) Scotland
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) July 25 1998
17 I HEREBY CERTIFY, That I attended deceased from
1918, to6
July 25- 1918.
DECKthat I last saw h .....
alive on
-
Bre 24= 1918.
and that death occurred, on the date stated above, at
.ym.
The CAUSE OF DEATH* was as follows :
Prostatitis
(duration)
.. yrs ...
............. mos ... ds.
(SECONDARY)
CONTRIBUTORY
arteriosclerosis
3
(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 ?
(Signed)
7/27.19/8 (Address) Princetout, El Boston
* State the DISEASE CAUSING DEATII, 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
Withnoto Cut
DATE OF BURIAL
7- 28/1918
20 UNDERTAKER W.C. Skaggs
ADDRESS Winebar
1 PLACE OF DEATH
County
Suffolk
Township
Winthrop
City
(a) Residence,
No. 175 main
(Usual place of abode)
Length of residence in city or town wbere death occurred
3 SEX
7:11
4 COLOR OR RACE
w
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
Months
Days
8
15-
63
8 OCCUPATION OF DECEASED
9 BIRTHPLACE (eity or town).
(State or country)
Scotland
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Scotland
PARENTS
14
Lameg White In
Informant
(Address)
175 Main SK
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
15
., 19
Filed
N. D. - WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD. Every frem of information should be
(b) General nature of industry,
business, or establishment in
which employed (or employer).
(c) Name of employer
B. Bostonterrier
or
St.,
Ward.
(If non-resident give eity or town and State)
KEVISLU UNIILD SIALES STANDARD CERTIFICATE OF DLAIII [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) 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," 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, cte. 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 "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronehopneumonia ("Pneumonia," unquali- fied, is indefinite); 'Tuberculosis of lungs, meninges, peri- loncum, 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; Chronie interstitial nephritis, cte. 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 symnp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"" "Debility" (“Con- genital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," ete., when a definite disease can be ascertained as the eause. Always qualify all diseases resulting from ehild- 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 carbolie acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. 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, 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, cte.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
HYMAN PAUL
Registered No.
7611
Place of Death | and Residence 1
Boston
MASS.GEN.HOSPT .
Date of Death
JULY 27
10
years 3
months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID .. DIV.
M
W
S
Maiden Name
Husband's Name
BOSTON
Birthplace
Name of Father
ISRAEL B.PAUL
Birthplace of Father RUSSIA
Maiden Name of Mother
ETTA DANBERG
Birthplace of Mother RUSSIA
Occupation
Informant
PHYSICIAN'S CERTIFICATE.
1918, I HEREBY CERTIFY that I attended deceased during last illness, from 1918, to 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:
ST
AR
R
(Durata
CITY
SI
SOFFICE
OPR.JULY 26.1918)
SULVILALO
BOSTONIA CONDITA.A.
₹ A.1822
8
TISREGIM 16 30. IMINE DONATA
STON
. MASS Contributory: { (Duration )
PERFORATED TYPHOID ULCER - 36 HOURS
(Signed)
H.W. HERSEY
M.D
1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial
or removal
Undertaker
BETH ABRAHAM
J. STANETSKY
Usual Residence
WINTHROP (287 SHIRLEY ST)
Filed
JULY 31
1918.
A true copy.
Attest :
Registrar.
TYPHOID FEVER - 1 1-2 MONTH
pratis
PATRIBU
1918, Age
July 27, 1918
-
County. Township City 2 FULL NAME 3 SEX Hernale 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. IN. D. WITTE PLAINLI, WITTY UNPADING INK THIS IS A PERMANENT NEVUND. Every fem of formation should be (State or country)
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Hinterof (City or town)
1 PLACE OF DEATH
State
Mass
Registered No.
No.
or Village Matcall Nochital
St.,.
.. Ward
(If death occurred in a hospitalfor institution, give its NAME instead of street and number)
Agnes Mary Forman Morgan
(a) Residence.
No. 08 Atlantic
St.,
Ward.
(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 birtb ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Inarrical
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of William it! morgan
6 DATE OF BIRTH (month, day, and year)
7 AGE
44
Ycars
Months
Days
If LESS than I day, ........ hrs. or ........ mio.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kiod of work
At Store
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
Boston
10 NAME OF FATHER Peter
11 BIRTHPLACE OF FATHER (city ør town)
(State or country)
Vicland
12 MAIDEN NAME OF MOTHER mary Crane
13 BIRTHPLACE OF MOTHER (city or towy). (State or country)
Informant
Agnes morgan
(Address)
I aslantie It
15 Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
July 29
19 小
17 I HEREBY CERTIFY, That I attended deceased from July 25 1916, to hele, 29 19.
that I last saw her
alive on
, 19
and that death occurred, on the date stated above, at
1
m. The CAUSE OF DEATH* was as follows :
Santiciencia
(duration)
. yrs.
mos.
ds.
CONTRIBUTORY
(SECONDARY)
.. (duration)
.......... yrs ....... ........ mos.
ds.
18 Where was disease dontracted
if not at place of death ?
Did an operation precede death ?
Date of.
Was there an autopsy ?
What test confirmed diagnosis ? 1
(Signed)
1.1.5.
30, 1911 (Address) 35 Umactif St
* 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
Holy Leise malden
DATE OF BURIAL 7/31/18%
20 UNDERTAKER Holm F. I makey
ADDRESS
Winthrop
. .
or
(If non-resident give eity or town and State)
d
A
KLVISEU UNIILD SIALLS STANDARD CERTIFICATE OF DEATH [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) 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, 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 thius: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATII (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," 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 deatlı), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symnp- toms or terminal conditions, such as "Asthenia," "Anemia" (increly 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 iniscarriage, 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, 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 (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statcinent of cause of death approved by Committee on Nomenclature 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, ctc.
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.
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
Township
Winthrop
or Village.
or
St ..
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
mary C. CyjneEly
(a) Residence.
No
25 Lincoln Istacc
St.,
Ward.
(Usual place of abode)
Leogth of resideoce in city or towo where death occurred
years
months
days.
How long io U. S., if of foreigo birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
31 July
1918.
17
HEREBY CERTIFY, That I attended deceased from
, 1918, to Make 31ª
..... ,
1918.
that I
alive on
July 29 th
1918:
and that death occurred, on the date stated above, at
4 a
m.
The CAUSE OF DEATH* was as follows :
If LESS than
1 day, ........ hrs.
or ........ min.
Simile anterioschlesque
8 OCCUPATION OF DECEASED
At Hana
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Salam, Mass
10 NAME OF FATHER
John Figh ?
11 BIRTHPLACE OF FATHER (city or town) ..
(State or country)
12 MAIDEN NAME OF MOTHER derthhm
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Informant
(Address) 2.5 Semicolon Varvara
15
Filed , 19
REGISTRAR
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 ?
. ....
Climeal
(Signed)
Frank Bateman
M.D.
31/7, 1918 (Address)
Somerville, masa.
* 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.)
DATE OF BURIAL
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Pine Hice amely, Die Y. 7. aug 2
1918
20 UNDERTAKER
Thomas Fiftieth
ADDRESS
Ernest
City
3 SEX
7 AGE
(a) Trade, profession, or
particular kind of werk
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
(State or country)
4 COLOR OR RACE
2
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED, (write the word)
5a If married, widowed) or divorced
HUSBAND of
(01) WIFE of
Jamas Hernelly
6 DATE OF BIRTH (month, day, and year)
Years
obert 75
Months
Days
(duration)
many
.yrs ..
mos.
ds.
CONTRIBUTORY
senile myo carditis.
(SECONDARY)
(duration) many.
... yrs.
mos.
ds.
of certificate.
1 PLACE OF DEATH?
County
Suffolk
State
mass
Registered No. ..
No.
(If non-resident give city or town and State)
JINIY
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [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 terin 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. Thema- 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, 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- eated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
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