USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 139
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(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from discase unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is nceded.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly - or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following ahortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
-
UNITED STATES GOVERNMENT WAR DEPARTMENT QUARTERMASTER CORPS GRAVES REGISTRATION SERVICE PIER 2 HOBOKEN N. J.
ap
Sept. 19th 1921.
TRANSPORTATION OF CORPSE
PERMISSION IS HEREBY GRANTED TO CONVEY THE BODY OF THE FOLLOWING NAMED PERSON, WHO DIED OVERSEAS IN THE SERVICE OF THE UNITED STATES, FROM HOBOKEN, N. J. TO EAST BOSTON, MASSACHUSETTS AND SOLDIER ESCORT IS HEREBY AUTHORIZED TO ACCOMPANY SAID BODY IN TRANSIT.
FULL NAME OF DECEASED MC CORMACK, Daniel 2nd. Lt. Co.L, 320th Inf.
CAUSE OF DEATH K /A DATE OF DEATH 10/11/18
DEATH OCCURRED ON DATE STATED ABOVE WHILE SERVING WITH THE UNITED STATES ARMY IN FRANCE.
BODY DISINTERRED BY THE UNITED STATES GOVERNMENT IN FRANCE .
THIS BODY HAS BEEN PREPARED IN ACCORDANCE WITH THE REGULATIONS OF THE DEPARTMENT OF HEALTH OF THE STATE OF NEW ISSUANCE OF THIS SAID DEPARTMENT.
R. E. SHANNON, CAPTAIN, Q.M.C., U.S.A .. OFFICER IN CHARGE.
Daniel U. Mccormack
Oct. 11. 1918
4
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
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
19/0
f
(Month)
(Day)
(Year)
7 AGE
.. yrs.
mos.
ds.
Or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ...
(b) General nature of Industry,
business, or establishment i
which employed (or employer)
9 BIRTHPLACE
(State or country)
Wirtho f Iller
Contributory
(SECONDARY)
(Duration)
„yrs.
mos. .............
ds.
(Signed)
9-12, 1915 (Address)
Inthe it Must. Ti Suchean,
* 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 ...
Where was disease contracted, If not at place of death ?
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
(Informant)
(Address)
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town.)
1 PLACE OF DEATH
152
Herered ING.
Ward)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
( courtney"
? FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
isu
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
Bet
2
(Month)
(Day)
191
(Year)
17 I HEREBY CERTIFY that I attended deceased from
....
191.2 .... , to
191
that I last saw her alive on
c$ 12
191.
and that death occurred, on the date stated above, at .........
& m.
The CAUSE OF DEATH* was as follows :
trem veno birth (" ..? )
.(Duration)
............
...........
.yrs.
................ mos.
ds.
10 NAME OF
FATHER
Frank
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
Hauch Holman
18 BIRTHPLACE
OF MOTHER
(State or country)
Chelica
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
.......
20 UNDERTAKER
ADDRESS
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
$ DATE OF BIRTH
001- 12
If LESS than
! day ......... hrs.
2.
M.D.
Oct. 12/1918 0 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, Architeet, 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) 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 mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At 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 DEATII, 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 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); Mcasles; Whooping cough; Chronic valvular heart disease; Chronie 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 discases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," "PUERPERAL peritonitis," ete. 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, ete.
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 dcad, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County.
Suffolk
State
masa
Registered No.
Township
or Village.
or
City.
Winthrop
No 200
Somerset Com-
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 Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
(Usual place of abode)
Length of residence ia city or town wbere death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Male
4 COLOR OR RACE
W
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)
7 AGE
S13-
Years
Months
Days
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work
(b) General matere of industry, business, or establishment ia which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
(State or country)
10 NAME OF FATHER 94 G. Kellenberger
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country) Caninge, Masa
12 MAIDEN NAME OF MOTHER Ulma 4 Baile
13 BIRTHPLACE OF MOTHER (city or town) Boston
(State or country) mais
14
Informant
Nuno. Bailey
(Address)
200 Somerset av3.
15 Filed ...... 26. 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Och. 15. 19 /8.
17
I HEREBY CERTIFY, That I attended deceased from
Och. 15
19.18
to.
Oct. 15.
that I last saw how alive on , 19
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH" was as follows :
Still Low
(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?
Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
Millions & -Parto
(Signed).
M.D.
2, 19/ &(Address)
Watchhofs, mais,
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL 10 2/ 2018
20 UNDERTAKER
ADDRESS
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, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
Hellenstenger
St.,
Ward.
(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 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 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 statcinent; 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 Housckcepers 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. Carc 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 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," unquali- ficd, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, ctc., of_
(namne origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Mcasles (disease causing death), 29 as .; Broneho- pneumonia (secondary), 10 ds. Never report inere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (mcrely symptomatic), "Atrophy," "Col-
lapse," "Coma," "Convulsions," "Debility" (“Con- genital," "Scnile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite discase can be ascertaincd as the cause. Always qualify all discascs resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. 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, Suicidc, 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 strect, 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
PIIYSICIAN.
R 15. 2-'18. 100,000.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
MINNIE | DORR
Registered No. 13385
Place of Death 1 and Residence
Boston
Date of Death
OCT . 13
1918,
Age
53
years
months days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
S
Maiden Name
Husband's Name
Birthplace
CHELSEA
Name of Father
- -DORR
Birthplace of Father CHELSEA
Maiden Name of Mother -- DELMAR
Birthplace of Mother - -
Occupation
-
Informant
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:
STRAR
.
R IT PATRIBES DEMary ja (Duration9 HOBIS
OFFICE
CJVTI BOSTONIA CONDITAA.
A. 1822.
B 1630.
MASS.
--
(Signed)
A.J.COLLINS
M.D.
OCT . 13 1918 SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial
or removal
CHELSEA
Undertaker
C.H.FAUNCE
CHELSEA
Usual Residence
WINTHROP (WASHINGTON ST)
Filed 1918.
A true copy.
Attest :
OCT.21
ErMSlenen
Filed Mich. 27, 1919
Registrar.
CHR. VALVULAR HEART DISEASE
CITY
ILS REG TINE DONATA.
ST
Contributory : (Duration )
60 TOWNSEND ST
Oct. 13. 1918
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County
Hampden
State
mass.
Registered No.
Township
monson
or Village
12.
Stato Hurfurar
St.,
... Ward
or
City.
No.
......
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
De and P. Leonard
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.,
.Ward.
machine mass.
(a) Residence.
No.
(Usual place of abodc)
Length of residence in city or town where death occurred
3 years 4 months 28 days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
16 DATE OF DEATH (month, day, and year)
04.17
19/~
17
I HEREBY CERTIFY, That I attended deceased from
march 27, 1918, to.
04.17
1918
18.
that I last saw
alive on
19
and that death occurred, on the date stated above, at
3.55-01 ,m.
The CAUSE OF DEATH* was as follows :
If LESS than
1 day, ........ hrs.
or ........ min.
Cerebral hemorrhage.
8 OCCUPATION OF DECEASED
(a) Trade. profession, or
particular kind of work
Grocery Salesman
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
-
CONTRIBUTORY
(SECONDARY)
.(duration)
......... yrs ................. mos ..............
ds.
9 BIRTHPLACE (city or town).
Boston
(State or country)
man.
10 NAME OF FATHER James Leonard
11 BIRTHPLACE OF FATHER (city or town) ..
(State or country)
Scotland
12 MAIDEN NAME OF MOTHER
Isabel Lyon
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Scotland
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 ?
Francis zu vermuilt
M.D.
/c (Signed)
CZ , 19 /> (Address)
Palmer mass.
* 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.)
14
Informant
........
Records Mumscon Stale Horas (Address) Palmer - mars.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL 10/20-19/80
15 Filed 3c/18, 1918 Fueron & raul REGISTRAR
20 UNDERTAKER
S.M . Phillip-
ADDRESS
palmen
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.
PARENTS
8 Months
24
Days
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
January 23-1858
7 AGE 60 Years
(If non-resident give city or town and State)
0 0+ 16-
(duration)
.. yrs ................. mos ............
ds.
.......
ALTWL
[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,"
"Forcınan," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer -Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. It the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- catcd 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 "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- toncum, 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 need not be stated unless important. Example: Measles (disease causing death), 29 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as " Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapsc," "Coma," "Convulsions,"""Debility" (“Con- genital," "Scnile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," ete., when a definite discase can be ascertained as the causc. Always qualify all diseascs resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably 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 one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS
PHYSICIAN.
BY
---
R 15. 6-'18. 50,000.
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
14
Informant
Wife Annie Leonalice
(Address)
15 Filed
, 19.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX m
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
m
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Anno
Leonaline
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
68
Months
Days
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, professioo, or
teamster
particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
CONTRIBUTORY
(SECONDARY)
(duration)
.yrs ................. mos ..........
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
n2 Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
M.D.
118/19/ (Address) 336 Untheart Of
* 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.)
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