USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 118
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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 circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
.
R 15. 1-'18. 100,000.
3 SEX female 6 DATE OF BIRTH 7 AGE & OCCUPATION (a) Trade, profession, or particular kind of work 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (State or country) 12 MAIDEN NAME OF MOTHER PARENTS 13 BIRTHPLACE OF MOTHER (State or country) important. See instructions on back of certificate. 15 Filed ., 191 .. 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 6 66.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
CIPLACE OF DEATH Mutteroh
(No
214 Shirley
St. : ....... .Ward)
(City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married 1852 17
(Month)
(Day)
(Year)
or min. ?
.. yrs. At Home
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country )
Ireland
James Inc Closkey
freland.
infocons
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Daughter In Sommermann
(Address)
214 Stabile It Neultron
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Septembre
3
(Month)
(Day)
1918
( Year)
HEREBY CERTIFY that I attended deceased from
,
to
191
Lept 3, 1918
If LESS than day ... .. hrs. that I last saw h ........ ] .. alive on. Sept 2, 198
and that death occurred, on the date stated above, at 3Am.
The CAUSE OF DEATH* was as follows :
7 Stermach
(Duration)
yrs
.. rros. .
ds.
Contributory
(SECONDARY)
(Duration ) ... . .. yrs.
mos. .
ds.
(Signed).
19 F (A
(Address).
, M.D.
200 Planter1.
* 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).
At place
of death
.yrs.
mos.
ds.
State
... yrs.
In the
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
20 UNDERTAKER
malde
/
DATE OF BURIAL
Selve 5, 19
ADDRESS
E
Budget.
Foley
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] RESIDENCE 214 Shirley It. Nutenon
Cambridge, Mass
Registered No.
mos.
ds.
sept
3,1/18
a
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - I'recise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean 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 "hecessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Serrant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be 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- KASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
-
1
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of .. ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasm«) ; Measles, Whooping cough, Chronic valvular heart discasr, Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affeetion 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," "C'oma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Craemia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUEK- PERAL septicacmia," "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:
I. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starration, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, 85 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. 7-'17. 100,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
BOSTON (City or town)
1 PLACE OF DEATH
County
Suffolk
State Massachusetts Registered No.
Township
Wirthof
or
Village
No. 39 Engilside ane
St., ..
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Margaret a Knight
(a) Residence. No.
(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
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH (month, day, and year) 1865
7 AGE
Years
53
Months
Days
If LESS than I day ......... hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade. profession, or
particular kind of work
None
(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.
FOR WHAT ?
Was there an autopsy ?.
What test confirmed diagnosis ?...
Bagnogs . Downey
(Signed).
I.I.D.
(26219,18 (Address)
* State the DISEASE CAUSING DEATH, or in death's 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
"Hol, Caas" Malden
DATE OF BURIAL Se//5-1918
ADDRESS
Filed
, 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and ycar) Sept. 3 1918
17 HEREBY CERTIFY, THO
Attohded deceased from
19 .... 71 ... , to.
, 1918
that I last saw h alive on test 3 1918
and that death occurred, on the date stated above, at 4,80 a. m. m. The CAUSE OF DEATH* was as follows : Cancer of the uterus
(duration)
yrs.
mos.
ds.
9 BIRTHPLACE (city or town)
Parler
(State or country)
10 NAME OF FATHER
1. 12.
Paul Gardner
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Barter
12 MAIDEN NAME OF MOTHER Lucy Turning
13 BIRTHPLACE OF MOTHER (city or tewn)!
(State or country)
Barter
NAS
14 Husband
Informant
(Address)
29 Ingleside cuve
15
of certificate.
PARENTS
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
or
City
... Ward.
(If non-resident give city or town and State)
20 UNDERTAKER
R. C. July
[Approved by U. S. Census and American Public Health Association] DLAIL
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory, The ma- terial worked on inay 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, ete. Women at liome, 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 employcd, 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.
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 eercbrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- ficd, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, 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 (discase 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," "Coina," "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 causc. 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- 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 (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 violencc, 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
WINTHROP
(City or town)
1 PLACE OF DEATH
State
MASS
Registered No.
Township
WINTHROP
or Village
or
St., ............ Ward
No ..
83, LORING .R.D.
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
ELLEN BLAIS
(a) Residence.
No.
83 LOPING P.D.
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
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
WHITE WIDOWED
5a If married, widowed, or divorced
HUSBAND of FRANCIS X. A. BLATS
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
1846
Months
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
particular kind of work
AT HOME
9 BIRTHPLACE (eity or town).
(State or country)
IRELAND
10 NAME OF FATHER JOHN GPIMES
11'BIRTHPLACE OF FATHER (city or town)
(State or country) IRELAND
12 MAIDEN NAME OF MOTHER BRIDGET MCCORMACK
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
IRELAND
Informant
CHAPLES BLAIS
(Address)
83 LOPING PD.
15
Filed 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
19
5
17 I HEREBY CERTIFY, That I attended deceased from
2
that I last saw h ~ alive on
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows :
Lecturas
(duration)
. yrs ..... .... mos ... ds.
CONTRIBUTORY
(SECONDARY)
.(duration) .. yrs ... . mos. ds.
1
Did an operation precede death ?
:20) Date of
Was there an autopsy ?
What test confirmed diagnosis ?
Harry apfelly
II.D.
9/4.19/8 (Address)
* 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
9/6/18
19
HOLY CROSS MALDEN
20 UNDERTAKER
John F. C maley
ADDRESS
Winthrop
...
CouRONFOLK City 3 SEX FEMALE 7 AGE Years (a) Trade, profession, or PARENTS 14 .... IL I LAINLI, WILLI UNFADING IIVA - THIS IS A PERMANENT RECORD. Every item of information should be (b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer 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,
of certificate.
19/8 to.
19
72
9
18 Where was disease contracted
if not at place of death ?
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 ean 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, cte. But in inany 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- 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 causation), using always the same acecpted term for the same discase. 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, ete., 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) affeetion need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broneho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terininal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Comna," ""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 discases resulting from child- birth or iniscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State eause 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 fraeture 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 Noinenelature 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 Medieal 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, 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, ete.
4. Deaths under eireumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
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 PARENTS
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No . 10 Some are
adan Waldo
Time. wuthings
... ...
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX mare
4 COLOR OR, RACE
white
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the word)
married.
6 DATE OF BIRTH
July 10.18 18 (Month (Day)
(Year)
7 AGE
if LESS than ! day, ........ hrs.
70 yrs. 1 mos.
27
ds.
or ........ min. ?
8 OCCUPATION
(a) Trede, profession, or
particular kind of work
Machaut
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Baston Mass
10 NAME OF
FATHER
Henry S. Waldo.
11 BIRTHPLACE
OF FATHER
(State or country)
Boston Mass
12 MAIDEN NAMEEmma Haven OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
Boston Mass.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
O. N. Valdo
(Address)
.
15 Filed ... , 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
(Day) 6 198 (Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
natural Causes:
Presumably Candies
vascular disease, (Sudden death )
.. mos. .
ds.
Contributory.
(SECONDARY)
.(Duration)
.... yrs.
...
.. mos.
.. ds
(Signed)
M.D.
po. 7/18
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATHI, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL 01 HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death
yrs.
mos.
ds.
State
.. yrs.
mos.
ds .............
Where was disease contracted, if not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL DATE OF BURIAL Newton Cem Newton. Sept 10 191
20 UNDERTAKER 8.WatermanSau
ADDRESS
Boston
Writing (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
9943
St. : Ward)
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband @RESIDENCE
16 DATE OF DEATH
Sept
(Month)
17
- -
-
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 terin 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) Foreman, (b) Automobile factory. The material worked on inay form part of the second statement. Never return "Laborer," "Forenran," "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 shoukl be taken to report specifically the oceupations 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.
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