USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 133
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93 | Part 94 | Part 95 | Part 96 | Part 97 | Part 98 | Part 99 | Part 100 | Part 101 | Part 102 | Part 103 | Part 104 | Part 105 | Part 106 | Part 107 | Part 108 | Part 109 | Part 110 | Part 111 | Part 112 | Part 113 | Part 114 | Part 115 | Part 116 | Part 117 | Part 118 | Part 119 | Part 120 | Part 121 | Part 122 | Part 123 | Part 124 | Part 125 | Part 126 | Part 127 | Part 128 | Part 129 | Part 130 | Part 131 | Part 132 | Part 133 | Part 134 | Part 135 | Part 136 | Part 137 | Part 138 | Part 139 | Part 140 | Part 141 | Part 142 | Part 143 | Part 144 | Part 145 | Part 146 | Part 147 | Part 148 | Part 149 | Part 150 | Part 151 | Part 152
(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: Mcasles (disease causing deatlı), 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- inus," "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 miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATIIS 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 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 onc supposed to bc due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
L
R 15. 1-'18. 100,000.
1 PLACE OF DEATH
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
STANDARD/CERTIFICATE OF DEATH
Township
Fort Banks
State of
Massachusetts
Registered No.
(No.
Post Hospital. It. Banks Rnaco
Ward)
Tlf death occurred In a hospital or institution, give Its NAME Instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
mais
4 COLOR OR RACE
White
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
( Write the word)
6 DATE OF BIRTH
(Month)
(Day)
1 (Year)
7 AGE
alman
35
yrs.
mos.
ds.
8 OCCUPATION (a) Trade, profession, or particular kind of work
Saldiri
(b) General nature of Industry,
business, or establishment in
which employed (or employer)
u. S. army
9 BIRTHPLACE
(State or country)
Lundan
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
15
Flled 191
REGISTRAR
16 DATE OF DEATH "Septembre 29 191. (Year)
(Month)
(Day)
17 HEREBY CERTIFY, That I attended deceased from Seft 19 191 .___ , to ..
Sept 29'
191 __
that I last saw h-221. alive on -
Saft 29"
191.2,
and that death occurred, on the date stated above, at 2.J __ 2m.
The CAUSE OF DEATH* was as follows: Pneummine acute Lobar
double left upper and
lower right biber
(Duration)
yrs.
mos. .
9
ds.
Contributory.
( SECONDARY)
(Duration) yrs.
mos.
ds.
at Stammt /St freut
M. D.
(Signed)
Sept 30
191-$ __ (Address)
It Banks
*State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS OF INJURY ; and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS)
At place In the
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 Buffalo du
DATE OF BURIAL
Oct
191.8
20 UNDERTAKER
C. K. Bennison
ADDRESS .
6.47
11-3184
=
County
Post Hospital
or
Winthrop
Village
or
City
2 FULL NAME
Monsour Cehamly
W.EDICAL CERTIFICATE OF DEATH
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B .- Every itom of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
If LESS than
1 day, ____ hrs.
or ____ min. ?
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH .
[Approved by U. S. Census and Americau Public Health Association]
Statement of occupation .- Precise statement of occupation 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, 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 naturo 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., withcut 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, 0" .It 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- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUS- ING 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," unqualified, is indefi- nitc); Tuberculosis of lungs, meninges, peritonaeum, etc., Car- cinoma, Sarcoma, etc., of .- (name origin; “Can- cer" is less definite; avoid use of " Tumor" for malignant neoplasins); Measles; Whooping cough; Chronic valvular Heart disease; Chronic interstitial nephritis, etc. The con- tributory (secondary or intercurrent) affection need not be stated unless important. Example : Measles (disease (s.using death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal condi- tions, such as "Asthenia," "Anaemia" ( merely symptom-
atic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" (" Congenital," "Senile," etc.), "Dropsy," "Exhaustion,""Heart failure," "Haemorrhage," "Inani- tion," "Marasmus," "Old age," "Shock,"" "Uracmia," "Weakness," etc., when a definite discase can be ascer- taincd as the causc. Always qualify all diseases result- ing from childbirth or miscarriage, as "PUERPERAL septi- chaemia," "PUERPERAL 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 determine 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. )
NOTE .- Individual offices may add to above list of undesirable terms and refuso to accept certificates containing them. Thus the form in use in New York City states: "Certificates will be returned for additional information which give any of tho following discases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions; haemorrbage, gangrene, gastritis, erysipelas, meningitis, miscarriago, necrosis, peritonitis, phlebitis, pyaemia, septichaemia, tetanus." But general adoption of tho minimum list suggested will work vast improvement, and its scopo can be extended at a later date.
11-3184
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH .... (City or town)
1 PLACE OF DEATH
County
Suffolk
State
quant.
Registered No.
Township
Winthrop
No HI
or Village. Pater, T.1.2.
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME.
(If in the Army or Nayy of the United States, give rank, organization, ete.)
St.,
........
.Ward.
(If non-resident give city or town and State)
Leogtb of resideoce io city or towo where death occorred
years
mooths
days.
How long io U. S., if of foreigo birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
m
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Clara young
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
Months
Days
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED ,
(a) Trade, profession, or
Brutal Supplier
particular kiod of work ..
(b) General nature of industry. business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
Faunaica Plan
(State or country)
Trasa
10 NAME OF FATHER Calvin forny
11 BIRTHPLACE OF FATHER (eity or town)
Barista
(State or country) Muara
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (eity or town)
(State or country)
14
Informant .......
Clara young.
(Address)
41Batisseurs
15
Filed
........... ., 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Sept 29 1915
17
I HEREBY CERTIFY, That I attended deceased from
may
1918
to
Seft
29, 1918
that I last saw h.
alive on
Left
29
1918
and that death occurred, on the date stated above, at
730 P
m.
The CAUSE OF DEATH* was as follows:
Spastic Vinaplegia
CONTRIBUTORY
(SECONDARY)
X
(duration)
X
.yrs ................. mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death?
no
Date of.
200
Was there an autopsy ?.
What test confirmed diagnosis ?
nous
(Signed)
9/3/ 19/8 (Address)
7 wess
* State the DISEASE CAUSING DEATII, 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 spaec.)
DATE OF BURIAL
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
forest Hills Cut 10-1-108
20 UNDERTAKER
W.C. Skaggs-
ADDRESS Withinthe.
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
of certificate.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
. or
City ....
either-
(a) Residence.
(Usual place of abode)
C
PARENTS
(duration)
yrs mos. ds.
Sept. 29,19/8" 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 term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- ilor, Architeet, Locomotive engineer, Civil engineer, Stationary fireman, ete. 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 stateinent; 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. It the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonyın 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, etc., Carcinoma, Sarcoma, etc., of_
(namne origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 &s .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal 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," ete., 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," ete. 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.)
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 Crimina. 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
Place of Death / and Residence S
Boston
Date of Death
SEPT .29
46
years
months days.
STATISTICAL DETAILS.
SEX.
COLOR
SINGLE, MARRIED, WID., DIV.
F
W
S
Maiden Name
Husband's Name
BRONCHO-PNEUMONIA -FOLLOWING
Birthplace
ENGLAND
Name of Father
WILLIAM P.LARKIN
Birthplace
of Father ENGLAND
Contributory: (Duration)
--
Maiden Name of Mother
ANN COCHRANE
Birthplace of Mother
ENGLAND
Occupation AT HOME
Informant
(Signed)
H.G.MYRICK
M.D
SEPT .301918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT.FEW HOURS
Place of Burial or removal ST.JOSEPHS
Undertaker W.J. CASSIDY
Usual
Residence
WINTHROP(41 CUTLER ST)
Filed
OCT.4
1918.
A true copy.
Attest :
ErMSlenen
Filed Dec. 18 1918
PHYSICIAN'S CERTIFICATE.
1918, I HEREBY CERTIFY that I attended deceased during last illness, from 1918, to
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:
5 RAR
Promar
R asi (Duration) SOBIS
CITY
OFFICE
INFLUENZA -- 3 DAYS
CTVYTA BOSTONIA CONDITAAL
18 41. REGTMINE DONATA A. STON. MASS.
THERESA
LARKIN
Registered No.
11010
NEW ENG .HOSPT .
1918,
Age
Registrar.
1
CORD
Sept. 29,1918
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY, PHYSICIANS should stato 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.
15
Filed
191
REGISTRAR
16 DATE OF DEATH September 30 191.៛ (Year)
(Month)
(Day)
17
I HEREBY CERTIFY, That I attended deceased from
Sept 22d
191_2 __ , to
Sept 30m
191.5,
Seft 30th
that I last saw h222malive on
1912 ...
and that death occurred, on the data stated above, at
.m.
The CAUSE OF DEATH* was as follows: acute Lobar Pneumonia
Left and Lower right tobe
(Duration)
yrs.
- mos.
ds.
Contributory
(SECONDARY)
(Duration)
ds.
(Signed)
1st Lucent a K Sturmund
M. D.
Soft 304
191-9 __ (Address)
I Banks
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS OF INJURY ; and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS)
At place
of death
. yrs.
In the
. 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 Tyum Center mich.
DATE OF BURIAL
2.0
191.X
ADDRESS
11-3184
1 PLACE OF DEATH
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH
massachusetts
State of
Registered No.
Village
or
City
mass.
(No
Post Stopetal It Banks, masa. Ward)
[If death occurred in
a hospital or Institution, give Its NAME Instead of street and number.]
2 FULL NAME
Starry
Kapteyn
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE
Ithits
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
( Write the word)
Single
6 DATE OF BIRTH
October;
19.1894
(Month)
(Day)
(Year)
7 AGE 23
yrs
11
mos.
17
ds.
If LESS than
1 day. ____ hrs.
or ____. min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Saldiri
(b) General nature of Industry,
business, or establishment In
which employed (or employer)
U. S. army
9 BIRTHPLACE
(State or country }
Grand Rapids mich .
10 NAME OF
FATHER
Cornaluis1. Japtryn
11 BIRTHPLACE
OF FATHER
(State or country)
Stolland.
12 MAIDEN NAME
OF MOTHER
Ulier Sluitenbergs
13 BIRTHPLACE
OF MOTHER
(State or country)
Holland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
C. J. Kaptein
--
Ponts #1 Byron Center
(Address)
PARENTS
County
Post Hospital
Fort Banks
Township
or
Winthrop
20 UNDERTAKER
C. R. Benim
Seht 30 1918 REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation .- Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or terin on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples : (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," " 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, O" .1. 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 inay be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUS- ING 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 "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualified, is indefi- nitc); Tuberculosis of lungs, meninges, peritonaeum, etc., Car- cinoma, Sarcoma, etc., of .. - (name origin; “Can- cer" is less definite; avoid use of " Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The con- tributory (secondary or intercurrent) affection need not be stated unless important. Example : Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal condi- tions, such as "Asthenia," "Anaemia" (merely symptom-
atic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion,""Heart failure," "Haemorrhage," "Inani- tion," " Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascer- tained as the cause. Always qualify all diseases result- ing from childbirth or miscarriage, as "PUERPERAL septi- chaemia," "PUERPERAL 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 determine 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.)
NOTE .- Individual offices may add to above list of undesirable terms and refuso to accept certificates containing them. Thus the form in use in New York City states: "Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirthi, convulsions, haemorrhage, gangreno, gastritis, erysipelas, meningitis, miscarriago, necrosis, peritonitis, phlebitis, pyaemia, septichaemia, tetanus." But geucral adoption of the minimum list suggested will work vast improvement, and its scopo can be extended at a later date.
11-3184
County Township City ... 3. SEX Male PARENTS 14 Informant of certificate. 15 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, 32
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.