USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 128
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5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
1895
7 AGE
23
Ycars
Months
Days
If LESS than 1 day, ........ hrs. or ....... min.
8 OCCUPATION OF DECEASED saleslady (a) Trade, profession, or particular kind of work
(b) General mature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
(State or country)
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city or town) ....... (State or country)
12 MAIDEN NAME OF MOTHER . Margaret Jord 0, 19 ( Address)
13 BIRTHPLACE OF MOTHER (city or town) ... ) ... (State or country)
14 Informant (Address)
15
Filed
, 19
REGISTRAR
16 DATE OF DEATH (month, day, and year) Select. 25 19
17
I HEREBY CERTIFY, That I attended deceased from
1/7-14
18
to
Sett. 25 19
that I last saw h
alive on
Leff 24
,19
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows :
Fits /Incomincia
(duration)
1
yrs.
mos .....
ds.
CONTRIBUTORY
(SECONDARY)
.(duration)
yrs ...
mos ...
ds.
18 Where was disease contracted if not at place of death?
Did an operation precede death?
100
Date of.
Was there an autopsy ?
FOR WHAT ? L
What test confirmed diagnosis ?
(Signed)
M.D.
1
* 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
9/28
1018
20 UNDERTAKER
ADDRESS
So. Boston
of certificate.
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
City
BOST.ON
No.
S. Barton
(If non-resident give city or town and State)
MEDICAL CERTIFICATE OF DEATH
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Preeise statement of oeeupa- 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 oceupations a single word or terin on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architcet, 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 preise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ete. 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, ete. It the occupation has been changed or given up on account of tlic 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 oceupation 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, ete., Carcinoma, Sarcoma, ete., of_
(name origin; "Caneer" 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 (discase causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (increly symptomatie), "Atrophy," "Col- lapse," "Comna," "Convulsions,"""Debility" ("Con- genital," "Senile," cte.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shoek," "Uremia," "Weakness," cte., when a definite disease ean be ascertained as the eausc. Always qualify all diseases resulting from ehild- birth or miseurriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," cte. 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 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 violenec, as Burns, Falls Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly eaused 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, cte.
4. Deaths under eireumstanees unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
-
R 15. 2-'18. 100.000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Suffolk
State
Masa.
Registered No ......
Township
or Village.
or
City
Winthrop
No.
Hb Tewksbury
St.,
Ward
(If death occurred in a hospital or institution, give its NAVE instead of street and number)
2 FULL NAME
Miriam Ruthy Hoffe
(If în the frits of ary of the Whites stites, frank organyinton;
(a) Residence.
No.
46 Tewksbury St.,
Ward.
Length of residence in city or town where death occurred
years
months
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3(SEX
Female
4 COLOR OR RACE
W.
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)
april 191
7 AGE
Years
1
Months
5
Dars
If LESS than
I day, ........ hrs.
or ....... min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
Willing W.Va.
(State or country)
10 NAME OF FATHER
Frank & Hoffe
11 BIRTHPLACE OF FATHER (city or tow
(State or country)
12 MAIDEN NAME OF MOTHER Rose Kovits
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
Phil Pem
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Sept 25 1918
17
I HEREBY CERTIFY, That I attended deceased from
Sent 20
1914, to.
Serv 25, 1918.
that I last saw hw alive on
Sept 21 1918.
and that death occurred, on the date stated above, at 12.00A.m. The CAUSE OF DEATH* was as follows :
Robar Pneumonia
(duration)
yrs.
mos ...
3.
. ds.
CONTRIBUTORY
ImporcondiTà.
(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 ?.
200
What test confirmed diagnosis ?
(Signed
Eli Frederico
(Address)
86 Buy Sta14 /20
M.D.
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
of certificate.
14
Informant
Mr. Kovits
(Address)
2) Queent IS Do. Wolum, Kenneth Savent
15
Filed
.... ... , 19
REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
Just 20 1918
20 UNDERTAKER
laerke Startal
ADDRESS
Martes
Winthrop (City or town)
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
PARENTS
(Usual place of abode)
(If non-resident give city or town and State)
(SECONDARY)
ACFIDEU UNLIEU DIALES SIARDAND CERTIFICAIG UF DEAIII [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 ına- 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. 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 Nonc.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fed, 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); 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 Gs .; 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." 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- 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 snicide. 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. Deathis 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.
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
14 En Jimathis Foley
Informant
(Address)
173 Thaler HAglede
15
Filed
...... , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Sept. 26. 2018.
17 I HEREBY CERTIFY, That I attended deceased from Sept. 3.5. 19/8, to Refah 206, 1918.
that I last saw her
alive on
19.
+8
and that death occurred, on the date stated above, at 100 .m. The CAUSE OF DEATH* was as follows :
Suplicenza
(duration)
yrs ..
mos ....
5
.ds.
CONTRIBUTORY
Organic
Heart Deviace
(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 ?
clement
(Sigoed)
M.D.
13 BIRTHPLACE OF MOTHER (eity or town Theland state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
(State or country)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
20 UNDERTAKER
ADDRESS
&Bortor
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town)
1 PLACE OF DEATH
County.
Suffolk
State
Massachusetts
Registered No.
Township
Winthrop mase.
or Village.
or
City
BOSTON
No.
173
Shirley
...
St.,
Ward
"(If death occurred in a hospital or institution/give its NAME instead of street and number)
2 FULL NAME
alice
Holey
....
St.,
.Ward.
(Usual place of abode)
Leogth of resideoce io city or town wbere death occurred
years
months
days.
How loog in U. S., if of foreign birth ?
years
months
days'
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
CH
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
mand
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Timothy
6 DATE OF BIRTH (month, day, and year)
1874
7 AGE
44
Years
Months
Days
-
If LESS thao
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, professioo, or
particular kind of work
Housewife
(b) General nature of industry, business, or establishmeot in which employed (or employer) (c) Name of employer
Ireland
9 BIRTHPLACE (city or town).
(State or country)
10 NAME OF FATHER George
11 BIRTHPLACE OF FATHER (city or town).(.
(State or country)
or tom) reland
PARENTS
12 MAIDEN NAME OF MOTHER Many fechar 2/3% 19/8 (des)
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES,
....
( Wanthugh Mars
(a) Residence.
No 173 Thislash
(If non-resident give ofty or town and State
DNIOVAN WRITE PLAINLY, WITH
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, 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) Collon mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile faelory. 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 domestic 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 may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronehopneumonia ("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; Chronie 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 .; Broneho- 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," ete., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- terniine 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, 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.
1 15 2-'18. 100.000.
N. B. - Every Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See Instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No. 12
Oakland
St.
....
............ .. Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Leah J Mitchell
Barrett, Buy Mitchell.
[If married or divorced woman or widow give maiden name, algo name of husband.] @RESIDENCE Thinthros- 17 Rakland
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
(Month)
(Day)
If LESS than
1 day ......... hrs.
ds.
or. .min. ?
9 BIRTHPLACE
(State or country)
Freuegarden, Va
10 NAME OF
FATHER
John W. Barrett
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
mitchell
(Address)
12 Oakland St
16 Filad 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
....
1849 17
...
(Year)
7 March 30
1918
to
Schefs"
1915
.. .
that | last saw h.fl
alive on
Scht 25
1915
and that death occurred, on the date stated above, at
12,5€
.m.
The CAUSE OF DEATH* was as follows :
arteru sclerosis
Hypertrophy & dellatation of ficaste
Hickscomer (Duration)
.. yrs.
ds.
Contributory
tendocardite
(SECONDARY),
chicken (Duration)
............. yrs.
......
mos.
ds.
(Signed)
Horace & Sauce
M.D.
1915 (Address)
11 million
* 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.
..........
In the
ds.
State
.......... y:s.
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
Acaban 9-29. 199
ADDRESS
20 UNDERTAKER
W.C. Skagav Whether
WRITE PLAINLT, WITH ONFADING INK - THIS IS A PERMANENT RECORD.
1 PLACE OF DEATH
Winthrop
2 FULL NAME
3 SEX
{ COLOR OR RACE
Ethiopian
· DATE OF BIRTH
7 AGE
70 y0
mos.
& OCCUPATION
(a) Trade, profession, or
.....
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
PARENTS
-
18 BIRTHPLACE
OF MOTHER
(State or country)
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
particular kind of work
athome.
(City or town.)
Registered No.
9
(Month)
(Day)
26
191 >> (Year)
...........
... mos ..
.........
Sept. 26 , 1918
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. 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 may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborcr, 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 homc. 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 lias 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 110 occu- pation whatever, write None.
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