USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 116
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" Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, 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- 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 faet 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 eausation), 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- 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- mus," "Old age," "Shock,"Uremia." "Weakness," ete., when a definite disease can be ascertained as the cause. Always qualify all discases 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 one supposed to be due to Alcoholism, etc.
4. Deaths under eircumstances 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)
1 PLACE OF DEATH Ludek County.
State
Registered No.
Township
.or Village ..
38
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
(a) Residence. No
(Usual placc of abode)
Length 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
3 SEX
male,
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 (month, day, and ycar) Eng 16-18
7 AGE
Ycars
Monthis
Days
2
If LESS than I day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
Z
(a) Trade, profession, or particular kiod of work
2
(b) Geoeral oature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town) (State or country) mais
10 NAME OF FATHI Simeon L. Gewer.
PARENTS
11 BIRTHPLACE OF FATHER (city or town) ...
(State or country) -art.
12 MAIDEN NAME OF MOTHER Ruck le lack.
13 BIRTHPLACE OF MOTHER (city or town)
(State or country) mexico.
14 Simeon & aura
Informant
(Address)
15 Filed ., 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Chung, 18 1918.
17 I HEREBY CERTIFY, That I attended deceased from
aug.
-8
19.
to.
Queky: 18
19 .. / 8.
that ) last saw h.
and that death occurred, on the date stated above, at 5.0 m. The CAUSE OF DEATH* was as follows :
Premature Perch
(duration)
2
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,
Clinical
What test confirmed diagnosis ?
(S:goed)
MG. Para
5/19, 19 (Address)
Windows, Mans.
LI.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
8/22
19 ¢ d)
20 UNDERTAKER
ADDRESS
Wonchut
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,
or
City
No.
Owen
St., .Ward.
(If non-resident give city or town and State)
-
casalive on
aug. 17, 1918.
yrs ...
mos.
REVISED UNIILD SIAIES SIANDAKU CERTIFICATE OF DEATHI [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 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 houschold 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- catcd 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 diseasc. 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- toneum, ctc., 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,' "Ancmia" (mcrely 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 eause. 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,
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.
15-'17-XXM |
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Unichrop, mass ( No. 7.0 Sagamore Que St. .Ward)
BOSTON
......... ..
(City or town.) [If death occurred in e hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
Jauna /grinsmaid Ment
Widow of nathaniel & Jeux
{If married or divorced woman or widow give maiden name, also name of busband.] @RESIDENCE 70 Sagamore Que ianthropo
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
aug.
(Month)
no ..
.. 191
(Year,
(Day)
-- 4
8
I HEREBY CERTIFY that I attended deceased trom Raly 15 8
to 191 aug. 20. 1918 that I last saw her alive on acq, 19. 198 and that death occurred, on the date stated above, at.m. The CAUSE OF DEATH* was as follows :
Organic Le each Derece
Did a surgical operation precede death ?
Date
Under, (Duration) yrs. .......
mos.
„ds.
Contributory Cardiac & Renal None
(SECONDARYY
(Duration)
... yrs.
mos. ds.
(Signed)
M.J. Partes
M.D.
191.0
(Address)
Nenitrox
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death
... yrs.
... mos. .
.........
ds.
State
....... yrs. ............ mos. .....
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Verona milli new York.
DATE OF BURIAL
areg. 2: 1918
20 UNDERTAKER
(ia Pallier.
200 meride aus
ADDRESS
E. Boston.
important. See instructions on back of certificate. N B - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very La Pallice, Embalmer
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country}
Litchfield, Corn
12 MAIDEN NAME
OF MOTHER
Lucy Call
13 BIRTHPLACE
OF MOTHER
(State or country)
Litchfield. Com
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
mies Reux daughter
(Address) To Lagamore are wia
15 Filed
191
REGISTRAR
5 SINGLE.
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widow
DATE OF BIRTH
Dec.
(Month)
(Day)
(Year)
7 AGE
If LESS than [ day ........ hrs ..
70
8
mos.
5
............ yrs.
ds.
Or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Housewife
(b) General nature of Industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
augusta, n.y.
10 NAME OF
FATHER
James Judson
1845
17
* SEX
Female
4 COLOR OR RACE
white
15
.
STANDARD CERTIFICATE OF DEATH.
1
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healtlifulness of various pursuits can be known. The question applies to caclı 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 wlien needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (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 "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber .
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ..... ...... ...... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affcetion need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Scnile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15. 1-'17. 100,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Dr. Reading (City or town)
1 PLACE OF DEATH
County ... idd1090x
.State.1.3.5.
Registered No.
Township .... No ..... Reading
or Village
.or
City.
No ...... N.O.,
Reading State Sanatorium
St ..
... Ward
(If death occurred in a hospital or institutlon, give its NAME instead of street and number)
2 FULL NAME
Hirs. Bertha HI. Gray
(a) Residence. No
20 Ocean Ave. Winthrop, lags.
Ward.
(If non-resident give city or town and State)
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
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Harried
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
David E. Gray
6 DATE OF BIRTH (month, day, and year)
7 AGE
33
Years
Months
0
Days
10
If LESS than
I day, ........ hrs.
or ....... min.
8 OCCUPATION OF DECEASED
(a) Trade. profession, or
particular kind of work
Housewife
(b) General aature of industry,
basiness, or establishment in
which employed (or employer)
(c) Name of employer
CONTRIBUTORY.
(SECONDARY)
Prof.
(duration)
3
mos
.yrs
21
ds.
4
9 BIRTHPLACE (city or town)Mass
(State or country)
10 NAME OF FATHER
Harry Hamblin
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
ST.Helena
12 MAIDEN NAME OF MOTHERlizabeth Hovland
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Mass.
18 Where was disease contracted
if not at place of death ?
Not from
Did an operation precede death ? 226 Date of
Was there an autopsy ?.
What test confirmed diagnosis ?
/ (Signed).
I. R. Jenbelow
M.D.
/24, 1918 (Address)
No. Reading State Sanatorium
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (I) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
14
Informant Hospital-Recorte .........
(Address)in Wilmington Wann
15 Filed Drug, JO 1918 H.L. NHL. 47.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) ang, 23 1918
17
I HEREBY CERTIFY, That I attended deceased from
May 2
13.
18
ang. 23
1918
that I last saw her
alive on
ang. 23
1918.
820 P.
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as followa :
Tuberculosis of Lungo.
Prof.
. (duration)
1
.yrs.
4
mos.
+
ds.
Chronic Nephritis
1
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Oak grove Com
Falmouth, Bro
DATE OF BURIAL
aug. 261918
20 UNDERTAKER
7. L. Edgely
ADDRESS
Reading Ms.
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.
(Usual place of abode)
21
[Approved by U. S. Comoms 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 agc. 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 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- eifically 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statoment 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 synonyın is "Epidemie eerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- ficd, 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 ncoplasms); 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," "Ancinia" (merely symptomatic), "Atrophy," "Col- lapse," "Comna," "Convulsions,"" "Debility" ("Con-
genital," "Scnilc," 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- 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 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, Homicide, etc.
2. Deaths supposedly eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ete.
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. 20,000.
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 annie Makes
Informant
(Address)
41 Bischo St. Wenttrop
15 e Luz 28, 1915/ Clifford Entuich
REGISTRAR
16 DATE OF DEATH (month, day, and year lucas. 27
1918
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) Jan. 24-1917
7 AGE
Years
Months
Days
1
7
4
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
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