USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 13
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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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop (No.61 Court Poad
St. ;................ .Ward)
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME Stillborn Leach [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE el Court Road
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) Single
Viale
White
& DATE OF BIRTH
April (Month)
5
(Day)
(Year)
7 AGE
If LESS than 1 day ......... hrs.
yrs. mos. ds.
Or ........ min. ?
& OCCUPATION (a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Winthrop
Nass.
10 NAME OF
FATHER
Trank T. Leach
PARENTS
12 MAIDEN NAME
OF MOTHER
Gertrude A. Furke
1$ BIRTHPLACE
OF MOTHER
(State or country)
Fast Boston Wasa
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) Frank J. Leach (Address) 61 Court Poad
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
(Year)
17 1 HEREBY CERTIFY that I attended deceased from [ , 1916 , to .....
1916
that I last saw hw alive on
191
.... ,
and that death occurred, on the date stated above, at
...... m. The CAUSE OF DEATH* was as follows : Billborn
(Duration) .............. yrs. ................ mos. ds.
Contributory (SECONDARY)
(Duration) ............... yrs.
.. mos. .. ds.
(Signed)
af1 5
1916 (Address)
* 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 ............ yro.
........... mos. ..........
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
St. Michaels Cemetery Pox.
An.r.i ........ 5 ..
191
20 UNDERTAKER *
ADDRESS
John F. O'Naley
Winthrop
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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
important. See Instructions on back of certificate.
16 Filed , 191
.........
M.D.
11 BIRTHPLACE OF FATHER (State or country) Boston Mass.
----------
...........
1916
....
apr. .. 1 -
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applics 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, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many eases, 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 necded. 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 minc, etc. Women at home, who are engaged in the duties of the household only (not paid House- kecpers 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 domestie service for wages, as Scrvant, 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 Nonc.
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 synonyın is "Epidemic cercbro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broneho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, ete., 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) affection 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- aemia" (merely 'symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
.............. ........ inthror ...
NIE Faun Far Ave St. ;... Ward)
(City or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
.... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
1 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) Widoved
18 DATE OF DEATH
aforx
14
1916
....
(Month)
(Day) - (Year)
I DATE OF BIRTH
White
(Month) (Day)
....
(Year)
! AGE
If LESS than
I day ......... hrs.
68
yrs. ............ mos. ..............
ds.
..... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
......
Petirod
(b) General nature of industry, business, or establishment i which employed (or employer).
9 BIRTHPLACE
(State or country)
Ireland
10 NAME OF
FATHER
PARENTS
12 MAIDEN NAME
OF MOTHER
Unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
Inland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
I. .. League
(Address)
15 Faun Far Ave
16
Filed
191
REGISTRAR
...
17 I HEREBY CERTIFY that I attended deceased from
1915 to Chux 14, 191 6 191 that I last saw him alive on fici 13 6 and that death occurred, on the date stated above, at m The CAUSE OF DEATH* was as follows :
Gastro-Centeretía
.(Duration)
........ yrs.
.......
mos.
20 ds.
Contributory.
Bau stories "e plerio acte quis
(SECONDARY)
(Duration)
5
.. yrs. +
.. mos.
............. ds.
(Signed)
M.D
alv 14, 1996
(Address)
Sunucu, mas.
* 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
DATE OF BURIAL
St. Marys Rye New York
April 11
191
20 UNDERTAKER John F. 0'Naley
ADDRESS
inthron
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 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.
Michael Fafrett-
......... ... .
11 BIRTHPLACE
OF FATHER
(State or country)
Treland
......
MEDICAL CERTIFICATE OF DEATH
"FULL NAME
JOHM /FARBETT
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 15 Foun Far Ave
apr. 14, 1916
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 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, Compositor, Architect, Loco- motive enginecr, Civil engincer, 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 nceded. 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- kcepcrs 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 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 indicated thus: Farmer (rctircd, 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 discase. Examples: Ccrebro-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-
culosis of lungs, meninges, peritonaeum, ctc., 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, ctc. The contributory (second- ary or intercurrent) affection 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- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," 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 strcet, or one supposed to be due to Alcoholism, etc
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15-8.'15. 100,000.
/
2.
-------
-------
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
10
(City or town.)
[If death occurred În a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
COLOR OR RACE
White
SINGLE,
lumia
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
10 DATE OF DEATH
april
(Month)
14.
(Day)
....
(Year)
$ DATE OF BIRTH
Luly
10
(Month)
(Day)
18%
(Year)
7 AGE
If LESS than
[ day ......... hrs.
36 yrs
9
4
mos.
.....
ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Accountant
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Concord Class
PARENTS
11 BIRTHPLACE
· OF FATHER
(State or country)
Marthen Walcott
12 MAIDEN NAME
OF MOTHER
Concord Klass
13 BIRTHPLACE
OF MOTHER
(State or country) Concord Class
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ...
Matee & Buran
(Add
)92 Binet Road Wenthaar
16
Filed
191 .......
REGISTRAR ....
17
I HEREBY CERTIFY that I attended deceased from
76.25
191
6. to.
March 22, 1916
that I last saw he alive on
Marche
22
1916
and that death occurred, on the date stated above, at S A m.
The CAUSE OF DEATH* was as follows :
Pulmonary Tuberculosis
(Duration)
1
... yrs.
................ mos.
.ds.
...........
Contributory
(SECONDARY)
(Duration)
yrs
ds.
mos.
(Signed)
Raymond B Parle
M.D.
april 14, 1916 (Address)
14,
Winthis Was.
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. ............ ds .......
Where was disease contracted,
If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
V14
......
191
20 UNDERTAKER
ADDRESS
Cambridge
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No. 92
Buch Road
St. ;.
.......
Ward)
...
? FULL NAME
Horace
Recde Bron
[If married or divorced woman or widow give maiden name, also name of busband.] .... a RESIDENCE 92 Beach Road Winthick
......
Registered No.
196
......
10 NAME OF
FATHER
Baseth & Brown
WATTE PLAINLT, WITH UNFADING INKINIS IS A PERMANENT RECORD.
ahs. 14 1916
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 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, Compositor, Architcet, 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 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 gaill- 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 witli respeet 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-
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) affection 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- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," 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 septicemia," "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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1916.
CITY OF BOSTON.
FULL NAME
JESSE P. SHURTLEFF
Registered No. 4217
Place of Death } and Residence
Boston
Date of Death
APR. 16
1916.
Age
64
years
8
months
7
days.
STATISTICAL DETAILS. .
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
M
Maiden Name
Husband's Name
Birthplace
COMPTON.P.Q. CAN
Name of Father
OTIS SHURTLEFF
Birthplace of Father
COMPTON.P.Q.CAN.
Contributory · (Duration)
TUB.KIDNEYS & BLADDER
50 YRS
Maiden Name of Mother
ELIZA PENNOYER
Birthplace of Mother
CANADA
(Signed)
E.D.LEE
M. D.
APR.16 1916 SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
CAMBRIDGE.MASS. (MT.AUBURN CREMATORY)
Undertaker A.E.LONG & SON
CAMB.
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from
1916, to
1916, that to the best of my knowledge and belief death occurred, on the date stated above, and that the CAUSE OF DEATH was as follows :
STRAR'S
T PATRIDUS. SIT DE Primary
ICU
( Durato
CIT
OFFICE
URAEMIA FROM URINARY SUPPRES- SION - 4 DYS
(OPR.APR.11.16)
CTVY
BOSTONIA
CONDITA AL
AT
ISREGIMI
1880.
NE DONATA A.
BOSTO
N. MASS.
Usual Residence
WINTHROP (5 HILLSIDE AVE)
Filed
APR.21 1916.
A true copy.
Attest :
ErMSlenen
Registrar.
1
Occupation
WATCH MAKER
Informant
MASS.HOMEO.HOSPT.
0 0
MARGIN RESERVED
FOR
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No. (No ), Waldemar avv.
St. ;. ... Ward)
......
Charles Colomer Eherman
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
71 Waldermon
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX male
4 COLOR OR RACE
Mitte
5 SINGLE,
MARRIED
WIDOWED.
OR DIVORCED
(Write the word)
· DATE OF BIRTH
mar 26 1866
(Month)
(Day)
(Year)
7 AGE
50
.. yrs.
mos.
31
ds.
Or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Salesman
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Patterson Ru
V
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Unknown
12 MAIDEN NAME
OF MOTHER
Sarah rady
13 BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
15 Filed 191
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
6
that I last saw her
alive on
1916
and that death occurred, on the date stated above,
6 Kg
m.
The CAUSE OF DEATH* was as follows :
(Duration) .
1 yrs. Y
.mos.
2
ds .
Contributory
Cecile Cardiac Selection
(SECONDARY)
5 minuti
(Duration)
(Signed)
Orville E. Jakson
M.D.
april 18, 1916
(Address)
* If death followed injury or violence the certificate of death must be made ont 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 ............ 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
Vincent- Charles 4/19
.......
1916
20 UNDERTAKER
ADDRESS
JO
483
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
191. (Year)
16 DATE OF DEATH
april
16
6
(Month)
(Day)
1916
april 18
to
191
If LESS than I day ......... hrs.
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
10 NAME OF
FATHER
Samuel Elevan
yTS. .............. mos.
----
------- ---
aps. 16, 1916
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. -- Precise statement of occu- pation is very important, so that thic 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, 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 linc is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Groecry; (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 minc, etc. Women at home, who are engaged in the dutics of the houschold only (not paid Housc- keepers who reccive 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. -- Namc, first, tlie DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, is indefinite) ; Tuber-
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