USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 115
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1 PLACE OF DEATH
County.
Suffolk
State Massachusetts Registered No.
Township
WINTHROP
or Village
or
City
No.
METCALF ... HOSPITAL
St ...
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME.MINNIE ... HAYES
(a) Residence.
No
WINTHROP ST.
St., ..
... Ward.
(If non-resident give city or town and State)
(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
FEMALE
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
WHITE
SINGLE
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
1893
7 AGE
Years
Months
Days
.
If LESS than
1 day ......... hrs.
pr ........ min.
8 OCCUPATION OF DECEASED
(a) Trade. profession, or
particular kind of work.
HOUSEICPK
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town)
I.P.ELAND
(State or country)
10 NAME OF FATHER
DANIEL
11 BIRTHPLACE OF FATHER (city or town)
IRELAND
(State or country)
12 MAIDEN NAME OF MOTHER
TINKNOWN
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
IPELAND
* 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
ST. JOSEPHS W. ROXBURY
DATE OF BURIAL
8/15//3
19
15 Filed
.,
19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Clave, 13 che
19 /8.
17
I HEREBY CERTIFY, That I attended deceased from
They 15.
19
to
Queg. 12.
1918
that I last saw her
alive on
13.
, 19/2 ...
and that death occurred, on the date stated above, at
6 0
m.
The CAUSE OF DEATH* was as follows :
Interstial Nephritis (Chronic)
CONTRIBUTORY
(SECONDARY)
(duration)
Unanunca
.. yrs ................. mos. .....
. ds.
(duration)
/
yrs ..
mos
.ds.
18 Where was disease contracted
if not at place of death ?
·zeuten www
Did an operation precede death ?
Zer, Date of.
FOR WHAT ?
Was there an autopsy ?
200
What test confirmed diagnosis ?
Cleucela Zucca
(Signed)
Millesof Paris
St. 19/8 (Address)
Matchup Vilans.
M.D.
PARENTS
of certificate.
14
Informant JOHN COSTIN
(Address)
IL CHURCH OD E. VILTON
20 UNDERTAKER
.FQ. maley
ADDRESS
n
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
25
KLVISLU UNUSED SIAILS SIANDAKD CLKIIFICAIL VI ULAIII [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) Forcman, (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 domestie 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 inay 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 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- toncum, etc., Carcinoma, Sarcoma, etc., of.
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; 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 terininal conditions, such as "Asthenia," "Ancmia" (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 ehild- birtli 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- terinine 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.)
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 discase, as A death upon the street, or one supposed to be duc 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
Winthrop -BOSTON -
(City or town)
1 PLACE OF DEATH
County
Suffolk.
.................
Township
.or Village ...
.. or
City
..........
St., ..
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Mary Sf. Moore
(a) Residence.
No ...
1620 Washington are
St.,
.. Ward.
(Usual place of abodc)
Length of residence in city or town where death occurred
year's
months
days.
How long in U. S., if of foreign birth ?
years
months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH'
(lng +4th ) am.
19
3 SEX
Y Su cale
4 COLOR OR RAÇE
Mule
5 SINCLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
16 DATE OF DEATH (month, day, and year)
17
I HEREBY CERTIFY, That I attended deceased from
May-1:21
19
28 to
to
am, 14th
, 1918.
that I last saw h.
er alive on
Cum13th
19.
18 and that death occurred, on the date stated above, at 7. a. The CAUSE OF DEATH* was as follows : m.
If LESS than I day, ........ hrs. or ........ min. Cancer of the Stomach
(duration)
.. yrs ....
4.
mos.
.ds.
CONTRIBUTORY
(SECONDARY)
(duration)
yrs .. .mos .... ds.
18 Where was disease contracted
if not at place of death?
I do not know.
Did an operation precede death?
200
Date of ..
What test confirmed diagnosis ?
(Signed)
Charles E Jun til
-- ,
M.D.
* State the DISEASE CAUSING DEATH, or in deathy from VIOLENT CAUSES. state (1) MEANS AND NATURE OF INJURY,and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
r
14 Edward moore
Informant
(Address)
162 Wash ave
15 Filed ., 19
REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR, REMOVAL Old Calvary Cem
DATE OF BURIAL Aug 16 19 7 x
20 UNDERTAKER
2.2 Burke
ADDRESS WROX 75 Chambers
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
PARENTS
10 NAME OF FATHER
John Mahoney
11 BIRTHPLACE OF FATHER (city of town
(State or country) Trela
12 MAIDEN NAME OF MOTHER HER Mary-
13 BIRTHPLACE OF MOTHER (eity or town).
(State or country)
Days
Years 64
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of werk ..
Est Home
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Boston
(State or country)
mass
FOR WHAT ?
200
Was there an autopsy ?.
4 Razy of Storach
8/14/19/8(Address)
of certificafé.
.State. Massachusetts Registered No.
No.
162
Washing Lin alex
........
(If non-resident give city or town and State)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Edward Moor
6 DATE OF BIRTH (month, day, and year) 1854
7 AGE
Months
44
REVISED UNITED SIAILS SIANDARD CERIIFILALE UK DEAILI [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 domestie service for wages, as Servant, Cook, Housemaid, etc. It 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 ferer (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; Chronie interstitial nephritis, etc. The contributory (sccondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 &s .; Broncho- pneumonia (sccondary), 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- ImIs," "Old age," "Shock," "Uremia,' "Weakness," etc., wlien 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 VOLENT 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 earbolie 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.)
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 duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
.
ADDITIONAL SPACE
FOR
FURTHER STATEMENTS BY PIIYSICIAN.
-
R 15. 2-'18. 100,000.
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.
14
Father
Informant (Address)
15 Filed Mento 19 /
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and ycar) aug. 15,
1918
3 SEX
m.
4 COLOR OR RACE
MI
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(01) WIFE of
>
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years 16
Months 5
Days
14
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
at school
(b) General nature of industry, business, or establishment ia which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Peabody mare
(State or country)
10 NAME OF FATHER Victor I.
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Salem Mars.
12 MAIDEN NAME OF MOTHER marie kladu
, 19 (Address) My15/18.@ask
* 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 Dr. Vanilé arlington
DATE OF BURIAL 1918
ADDRESS
20 UNDERTAKER
Helena a. Peltier
az
(City or town)
1 PLACE OF DEATH
County.
State
Thank.
Registered No. 1330
Township
Cambiago
City
No.
or Village. Tuberculosis It2 10
St.,
_. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Lawrence Valentine
2 FULL NAME
vence
(a) Residence.
No.
at Herman
St.,
. Ward.
Minitirato
(Usual place of abode)
Length of residence in city or town where death occurred
years
mooths
days.
How long in U. S., if of foreign birth ?
years
mooths
days
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
The CAUSE OF DEATH* was as follows :
Chr. Pulmonary Tuber.
culosis
(duration)
1
yrs ...
10
mos.
y. 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 ?
(Signed) Felix malsur -
M.D.
13 BIRTHPLACE OF MOTHER (city or town) (State or country) Peabody Mare
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
or
(If non-resident give city or ffown and State)
PERSONAL AND STATISTICAL PARTICULARS
7
C
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 cach 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 statcinent; 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 inay forin part of the second statement. Never return "Laborer," "Foreinan," "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 spc- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. It the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired froin 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 fevcr (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- ficd, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of.
(naine origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasins); 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 (discase causing death), 29 as .; 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," 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 iniscarriage, 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, 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 (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.)
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, Ilomicide, ctc.
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 FURTIIER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 20,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County.
SUFFOLK
State
Mass.
Registered No ......
Township
WINTHROP
Village
or
City.
No.
Metcalf Hospital
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Stillborn Nichols
(a) Residence.
No ...
23 Charles St.
St.,
......
Ward.
(If non-resident give city or town and State)
(Usual place of ahode)
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
Male
4 COLOR OR RACE
Thite
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)
ana. 17, 1918
7 AGE
Ycars
Months
Days 1
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
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 ?
(Signed)
I.I.D.
(1), 19/ (Address) 556 hvala fest
* 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
Winthrop Cemetery
DATE OF BURIAL
8/18/18
19 .
15 Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) ino. 17 1918
17
I HEREBY CERTIFY, That I attended deceased from 18 ing 1) 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 :
(duration)
yrs.
mos.
ds.
9 BIRTHPLACE (city or town)
(State or country)
10 NAME OF FATHER George
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
Glenwood
(State or country)
Mass.
12 MAIDEN NAME OF MOTHERFrances McGeorge
13 BIRTHPLACE OF MOTHER (city or town ast Foston (State or country) Mass.
14 George Nichols
Informant
(Address)
23 George St.
charly
20 UNDERTAKER
John F. O. maley
ADDRESS
Winthrop
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.
Winthrop, Mass.
X
m
-
KLYISED UNIILD SIAILS STANDARD CLATHICAIL OF DEALI [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. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager,"
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