USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 136
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So Loston
(State or country) Mass
12 MAIDEN NAME OF MOTHER Rosalie E. Wood
New York
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Oct. 2 2. 19 %.
17
I HEREBY CERTIFY, That I attended deceased from
Les. 25.
1918
Och. 22
,19 ... / 8.
to
that I last saw hu ....... [/ alive on
Och. 2 %
19.18.
and that death occurred, on the date stated above, at m. The CAUSE OF DEATH* was as follows :
Lober Pneumonia
(duration)
Influenza
yrs ..
mos.
3
ds.
CONTRIBUTORY
(SECONDARY)
(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 ?
clinical
What test confirmed diagnosis ?
(Signed)
3.19 4% (Address)
Greattrop, these.
* 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 spacc.)
Informant
William N. Jenkins
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Holywood.
DATE OF BURIAL
Oct / 1918
ADDRESS
15 Filed ... ,19
REGISTRAR
20 UNDERTAKER
John F. Comaly.
M.D.
(Address)
175 Pleasant St.
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be
24
5
20
avy of the United States, give rank, organization, etc.) St., Ward.
(If non-resident give city or town and State)
ONIOUJN JNA HLIM
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, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employinents, 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 domnestie service for wages, as Servant, Cook, Housemaid, ete. 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 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- loneum, etc., 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, ete. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing deatlı), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia." "Anemia". (inerely symptomatie), "Atrophy," "Col-
lapse," "Coma,"" "Convulsions,"" "Debility" ("Con- genital," "Senile," ete.), "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 ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably sueli, 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, ete.
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.
-
-
12 15. 1-'18. 100,000.
N. B .- Every item of Information should be carefully suppliod. 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.
1 PLACE OF DEATH
County Post Hospital
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH
State of
Massachusetts
Registered No. [If death occurred in a hospital or Institution,
-give Its NAME Instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
(Month)
u
191
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
aug 20
191 ..
-- , to
Oct 3
1918
that I last saw hous alive on
Det 3
1918,
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows: Cerebral Paresis
(Duration)
2-+ mos.
ds.
yrs.
Contributory
Syphilis Tertiary
(SECONDARY)
(Duration)
?
. yrs.
mos. ds.
(Signed)
Selman L. Chase
M. D.
Det 3
, 1918
(Address)
Fort Banks may
* 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.
mos.
ds. State
In the
yrs.
mos.
ds.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
( Informant)
(Address)
15
Filed Olet 7
191
REGISTRAR
16 DATE OF DEATH
WIDOWED,
OR DIVORCED
( Write the word)
6 DATE OF BIRTH
February 191892
(Month)
(Day)
(Year)
7 AGE 26
yrs.
1
mos.
14 .
I 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 conntry)
(5) Buffalo ny
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or conntry)
Where was disease contracted, If not at place of death ?
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Lake uwanna Hoy
DATE OF BURIAL Ock 25
P
191.
20 UNDERTAKER
ADDRESS
-
Fort Banks
Township
or
Hunthrop
Village
or
Mass, west Hospital, get Back Mars
City
Michael Carto
2 FULL NAME
3 SEX
mali Sluta
4 COLOR OR RACE
LoWED married
11-3184
3, 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 cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples : (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on 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 reccive a definite salary), may be entered as Housewife, Housework, 0" .16 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 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 CAUS- ING 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," unqualified, is indefi- nite); 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 deatlı), 29 ds .; Bronchopneumonia (sccondary), 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 refuse to accept certificates containing them. Thus the form in use in New York City states: "Certificates will bo returned for additional information which give any of the following discases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions. haemorrhage, gangrene, gastritis, erysipelas, meningitis, miscarriage, necrosis, peritonitis, phlebitis, pyaemia, septichaemia, tetanus." But general adoption of the minimum list suggested will work vast improvement, and its scope can be extended at a later date.
11-3184
-
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
NICOLAS RHODES
Registered No. 1 783
Place of Death and Residence
Boston
MASS .HOMEO .HOSPT .
Date of Death
OCT .3
1918,
Age
25
years
months
1 days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
S
Maiden Name
Husband's Name
Birthplace
GREECE
Name of Father
CHARLES RHODES
B
1681. OFMI TINE DONATA OSTON. MASS.
Contributory : (Duration)
(Signed) H.M.POLLOCK M.D.
OCT .4 1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal FOREST HILLS
Undertaker
C.R.BENNISON
WINTHROP
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from
1918, to
1918, 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:
IST
RAR
PATRIBUS Sacomary (Duration)
SOBIS
OFFICE
BOSTDNIA CONDITAA.
41.0.1022.
Birthplace of Father GREECE
Maiden Name of Mother
Birthplace of Mother GREECE
Occupation
RESTORATER
Informant
Usual Residence
WINTHROP (21 TAYLOR ST)
Filed
OCT.8
1918.
A true copy.
Attest :
Filed Dec. 18 , 1918
Registrar.
1
1
LOBAR PNEUMONIA (EPIDEMIC)
CITY
Olet. 3, 1918
ESER
0 OR BINDING
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
15
Filed .19 | ...
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
qu.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Harried
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Gertrude EMandry
6 DATE OF BIRTH (month, day, and year)
-1865
7 AGE 53
Years
Months
Days
If LESS than
I day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
Talman Manager
particular kind of work
Sewing Machine
(duration)
yrs.
mos.
ds.
CONTRIBUTORY
Intercorsa
(SECONDARY)
(duration)
.. yrs.
mos ..
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
Lo Date of.
Was there an autopsy ?
What test, confirmed diagnosis ?
(Signed)
M.D.
JC, 19/Y (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
Glenwood Crm. Everett,
20 UNDERTAKER
I.F. In: Glinchey
ADDRESS Chelsea 183 Buary
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(Gmvor town
1 PLACE OF DEATH
County ..
Jeffalle
Township
hip Winthrop
or
City
No.
or Village.
K av Winthrop
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
James D Jordan
(a) Residence.
No ...
(If in the Army de
y of the United States, give rank, organization, etc.)
St.,
Ward.
(If non-resident give city or town and State)
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
18
16 DATE OF DEATH (month, day, and year)
Oct. 4
19
17
I HEREBY CERTIFY, That I attended deceased from
1
19 11, to
2014
.19
, that I last saw h ............ alive on
Ut 4.
, 19
and that death occurred, on the date stated above, at
1
m.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE (city or town)
Milford
(State or country) FACIAS
PARENTS
10 NAME OF FATHER William Jordan
11 BIRTHPLACE OF FATHER (city or town) C. Clarke
(State or country) Irland
12 MAIDEN NAME OF MOTHER Mary Oconnor
13 BIRTHPLACE OF MOTHER (city or town) Co. Carl
(State or country) Irland
14
Informant
Gertrude E. Jordon
DATE OF BURIAL
Oct. 9
19/8
(Address)
119 Park Cur
State
Registered No.
(Usual place of abode)
119 Parte Cz
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
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 cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Forcman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return
"Laborer," "Foreman," "Manager," "Dcaler," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at hoinc, 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, ctc. 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 .- Namc, first, the DISEASE CAUSING DEATII (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 "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, ctc., Carcinoma, Sarcoma, etc., of_
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discasc; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (discase causing death), 29 ds .; Broneho- pneumonia (sccondary), 10 ds. Never report mere symp- toms or terminal conditions, such as " Asthenia," " Ancinia" (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 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 dc- 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 statcd
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 discase, 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 ... (City or town)
1 PLACE OF DEATH
County.
Suffolk
State.
mars
Registered No.
Township .
.. or Village
or
City
No. 49,
.....
Locusts.
St.,
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME.
alberto a Schlingmen=aviation suspect,
(a) Residence.
(Usual place of abode)
Length of residence in city or town where death occurred
1
years
3
months
days.
How loog in U. S., if of foreigo birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
marked
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
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, professioo, or,
Aviation Inspector
particolar kind of work
(b) General oature of industry, business, or establishmeot in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
St. Louis, mo
(State or country)
10 NAME OF FATHER Fred Schlingman
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country) Germany
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (city or town). (State or country) Germany
14 Vuns. elfurt Schling zu
Informant
(Address) 49 Frenet-25
15
Filed I .. .. 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) 19
17 I HEREBY CERTIFY, That I attended deceased from
19.7.
.. , to ....
19
that I last saw
alive on
1
, 19
.....
and that death occurred, on the date stated above, at
/
1
m.
The CAUSE OF DEATH* was as follows :
(duration)
.. yrs ..
mos ................ ds.
CONTRIBUTORY
(SECONDARY)
(duration)
............. yrs ..
.........
mos ... L.c ..... 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 ? 0
(Signed)
M.D.
10/J. 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. (Sec reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL 12-5 1015
ADDRESS
20 UNDERTAKER U. C. Ph= 2
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.
23
(If in the Army or No. If d'or Navy of the United States, give rank, organization, etc.) 1
St., .Ward.
(If non-resident give city or town and State)
Chat 4, 1718
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 agc. 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 inany cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer,"
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