USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 134
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1 PLACE OF DEATH
State
Illans
Registered No ....
or
-
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Theodore
Codward. 13 over
(a) Residence.
No.
135 Circut -Rd
St.,
Ward.
(Usual place of abode)
Leogth of residence in city or town wbere death occurred 4 years months
days.
Hlow long in U. S., if of foreign birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
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) Mich 4 -1886
7 AGE
Ycars
If LESS than
1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or Tilanager
particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
Boot of hore Busines
9 BIRTHPLACE (city or town)
Barton
(State or country)
10 NAME OF FATHER John Edward Bauer
11 BIRTHPLACE OF FATHER (city or town)
(State or country) 1 Lanton
12 MAIDEN NAME OF MOTHER Emily Truchales , 19 (Address)
13 BIRTHPLACE OF MOTHER (city or town) (State or country) ilrance
* State the DISEASE CAUSING DEATHI, 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
Honest Hill Permite
19/2
20 UNDERTAKER
ADDRESS
Filed ., 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Oct. 1,
19 /8
17 I HEREBY CERTIFY, That I attended deceased from Jest 23 19 ........ , to .. 19 ...
that I last saw hw alive on , 19.4.
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows : hotas y nemmences
(duration)
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?
Zwo Date of
Was there an autopsy ?.
What test confirmed diagnosis ?
(Sigoed)
LI.D.
(Address)
130 Jurent Rd Winteraly Czy
1
I
No.
or Village. 130 timent Road
(If non-resident give city or town and State)
Months
6
Days
27
wer
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 inany occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architeet, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- 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 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 ouly definite synonym is "Epidemic cerebrospinal mnenin- 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- 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 .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as " Asthenia," "Anemia" (increly 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 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 carbolie 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 deatlı 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 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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
winetwork (City or towny
1 PLACE OF DEATH
County ....
State ...............
Registered No ...
Township
or Village. No. 22, Frescatt Lt
St.,
Ward,
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
l'hasie
(a) Residence. No ... 22 Prescott
St., Ward. -
(Usual place of abode)
Lengib of residence in city or town where death occurred 2 years months
days. How long in U. S., if of foreign birth ? years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
vitré
-
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year) 6-13-1884
7 AGE Ycars
04
Months
3
Days
26
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
Book. Keeper
particular kind of work
Dwight hity. for
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer Boston Mais
9 BIRTHPLACE (city or town)
(State or country)
Easthart Marine
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ? no A Date of.
Was there an autopsy ?.
What test confirmed diagnosis ?
element
3. R. Pantes
(Signed)
, I.I.D.
12 MAIDEN NAME OF MOTHER Christine Leuron 1/2 , 19 (Address)
13 BIRTHPLACE OF MOTHER (city or town) ..
Gusthet-
(State or country)
11 arve/
14
Informant
(Address)
23 Prescott It Tuttinoi
15
T
, 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Oct. 1.
1918.
17 I HEREBY CERTIFY, That I attended deceased from theph . 3.5 1918 to. 19 18. that I last saw hice alive on Raph. 30 196 ..... and that death occurred, on the date stated above, at s. e. m. The CAUSE OF DEATH* was as follows :
....
(duration)
yrs ..... .. .. .. mos .. ds.
CONTRIBUTORY
Lafluenza
(SECONDARY)
.(duration) . yrs.
mos ..
12 ds.
10 NAME OF FATHER George In. Jarboy
11 BIRTHPLACE OF FATHER (eity or town)
Portland
(State or country) Marine
PARENTS
* 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
Palais Maine
DATE OF BURIAL Det 2 -2018
ADDRESS
1
20 UNDERTAKER
C. R. Dennisa
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.
Filed
(If non-resident give eity or town and State)
or
City .--
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- 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, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- 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 (ncver report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("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 neoplasıns); 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 death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con- genital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," 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 car olic 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.)
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.
4
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
Informant
(Address)
15
Filed 1, 19 T
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and ycar)
Out-1.
1018
17 HEREBY CERTIFY, That I attended deceased from ., to , 19 .. Sept 1948
that I last saw her alive on
19 .........
and that death occurred, on the date stated above, at
7.top.
.4 .. m.
The CAUSE OF DEATH* was as follows :
(duration) .yrs .. ... mos. .... ds.
CONTRIBUTORY
(SECONDARY)
(duration)
yrs.
mos.
4 ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death ?
.Date of.
Was there an autopsy ? 1.00
What test confirmed diagnosis ?
(Signed)
I.I.D.
1 ; 19 ( (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
Whatel.
20 UNDERTAKER
C. R. Bennism
ADDRESS Winte
Winthrop (City or town)
1 PLACE OF DEATH
County
Suffolk
State
maso
Registered No ..
Township
Winthrop
City
No.
or Village LO3 Shirky
St.,.
3
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(a) Residence.
No.
St., ...........
Ward.
(Usual place of abode)
Length of residence in city or town wbere death occurred
years
months
21
days .
How long in U. S., if nf foreign birtb ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
While
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
11
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
fought work
6 DATE OF BIRTH (month, day, and year) C/ 122, 859
7 AGE
Years
Months
5
Days
If LESS than 1 day, ........ brs. Ar ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, professinn, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
Bake house
9 BIRTHPLACE (city or town)
(State or country)
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city or town) Will it for (State or country)
12 MAIDEN NAME OF MOTHER
Chester Aura
13 BIRTHPLACE OF MOTHER (eity or town) (State or country)
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
or
DATE OF BURIAL Qui-5 19/
1
(If non-resident give eity or town and State)
1.4016
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Poblic Healtb Associatioo]
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, 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 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 forin 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. 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 DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. 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- ficd, 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; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection nced 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" (inerely 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 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, Of HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. g., sepsis, tetanus) may be stated
under the licad 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, Homieide, 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.
a.p.
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City Of town
1 PLACE OF DEATH
County.
Suffolk.
.State
Registered No ..
City
No.
(If death occurred in a hospital gr institution, give its NAME instead of street and number)
2 FULL NAME
L'âmes magenis
(a) Residence.
No ...
6 2-31. 6 must Road.
St.,
.Ward.
(Usual place of abode)
Length of residence in city or town where death occurred (50)
years
months
days. How long in U. S., if of foreign birth ? years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(01 ) WIFE of
6 DATE OF BIRTH (month, day, and year) May 25,1868
7 AGE Years
Months
4
8
If LESS than 1 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) north adama, Mase (State or country)
10 NAME OF FATHER Daniel B. Magenic
PARENTS
11 BIRTHPLACE OF FATHER (city or town) Taluy
(State or country) . Ireland
12 MAIDEN NAME OF MOTHER Mary Kelly
13 BIRTHPLACE OF MOTHER (city or town) Machoom (State or country) Ireland
14
Informant Jahn, E. maglina
(Address) Marcelo adama mase
15
T
Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Och.1.
19 8
17 I HEREBY CERTIFY, That I attended deceased from Reph, 2 9 18 to. 1918
.
18
that I last saw how alive on
Oct. 1.
19.
and that death occurred, on the date stated above, at 100. m. The CAUSE OF DEATH* was as follows :
(duration) ... yrs .... mos.
ds.
CONTRIBUTORY
Pernicious anarea,
(SECONDARY) in der
(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 ?
What test confirmed diagnosis ?
chemical
(Signed)
, 19
(Address)
I.D.
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Dachauer
DATE OF BURIAL
Oct.3,
19/8.
ADDRESS Hal.d.
20 UNDERTAKER
1
-
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,
Township
Il Ijuithol
or Village.
metcalf Hospital
St.,
... Ward
or
(If non-resident give city or town and State)
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of oceupa- 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 fircman, 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) Forcman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- 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.
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