USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 142
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19 .. 8
and that death occurred, on the date stated above, at 1-45 m. The CAUSE OF DEATH* was as follows :
* 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.) Pneumonia Lobur
.(duration) ................ yrs ...
............ mos ................ ds.
CONTRIBUTORY (SECONDARY)
(duration)
www .... + 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? cual W. George.
,19 ( Address)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Woodlawn Can. Everest
DATE OF BURIAL
19
20 UNDERTAKER Eduring, Brown ToSan.
ADDRESS
Earl Boston
so that it may be properly classified. Exact statoment 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,
2
21
If STILLBORN, enter that fact here
(If in the Army or Navy of the United States, give rank, organization,etc.)
(Place of residence)
27,
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 statcinent; it should be used only when necdcd. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on inay 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 home, who are engaged in the dutics of the houseliold 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. 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- eated 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 synonyın is "Epidemie ecrebrospinal 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- toncum, etc., Carcinoma, Sarcoma, etc., of.
(nanie origin; "Cancer" is less definite; avoid use of "Tumnor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- eurrent) affection need not be stated unless important. Example: Measles (lisease causing death), 29 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toins or terminal conditions, such "Asthenia,"
"Col- "Anemia" (merely symptomatie), "Atrophy," lapse," "Coma," "Convulsions,"" "Dcbility" ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shoek," "Uremia," "Weakness," ete., when a definite disease ean be ascertaincd as the eausc. Always qualify all discases resulting from ehild- 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 Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized discase, as A death upon the strcet, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 303. 6-'18. 50,000.
The Commomuralth of Massachusetts
STANDARD CERTIFICATE OF DEATH
BOSTON (City or town)
1 PLACE OF DEATH
County
Suffolk
State
Massachusetts
Registered No.
Township
City
BOSTON
No.
2 Stiglilana que
St .......
. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
arthuranding Sullivan
2 FULL NAME
(If in the Army of the United States, give rank, organization, etc.)
(a) Residence.
No
(Usual place of abode)
Length of residence in city or town where death occurred
years
Stay at the Unit
and live. St., Ward.
(If non-resident give eity or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
Mlute
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
Oct 291918
7 AGE Years
Months
Days
If LESS than I day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work.
(h) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (eity or town)
Nuittrofe
(State or country) Mais
10 NAME OF FATHER Eugene
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
Canbudas
mark
(State or country)
12 MAIDEN NAME OF MOTHE Fuldrad Corcoran
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Boalow
mass
14
Informant
Eugene Sullivan
(Address)
15
Filed 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
1918
17
I HEREBY CERTIFY, That I attended deceased from
Oct. 29,
19/8, to
Oct 29
19.48.
that I last saw
alive on
Cecf 29
19/01.
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows :
Imperfect hurt
(duration)
yrs .. ...
.mos.
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
.. yrs ..
18 Where was disease contracted
if not at place of death?
FOR WHAT?
Did an operation precede death ?
Date of.
Was there an autopsy ?.
no
What test confirmed diagnosis ?
(Signed) ...
, M.D.
10/29/ 19/18 (Address) 219 Fleralatin Rt.
* 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 Clet 3/ 19/8
20 UNDERTAKER
ADDRESS
Minttuoh
M.
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 Village.
or
months
days.
How long in U. S., if of foreign birth ?
years
mos .......
ds.
REVISIT UNITED STATES STANDART ESTE 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 domestie 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 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 need not be stated unless important. Example: Measles (discasc causing death), 29 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (mcrely symptomatic), "Atrophy," "Col- lapse," "' "Coma." ""Convulsions,"" "Debility" ("Con- genital," "Scnile," ete.), "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 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 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 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, ctc.
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.
his certificate based upon U.S. Army transportation Permit R-302 1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Winthrop (City or town)
Registered No.
(Place of death)
Registered No. 269 (Place of residence) St., Ward
No. (If death occurred in a hospital or institution, give its NAME instead of street and number) William a Miller Pfc. 62903, M. G. Co. 101st Infantry
(If in the Army or Navy of the United States, give rank, organization, etc.)
City or Town Winthrop No. 210 Pauline St.
Length of residence ia city or town where death occurred
years
months
days How long in U. S., if of foreign birth? years months days
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Oct- 30 1918
17
I HEREBY CERTIFY, That I attended deceased from
19 ............ , to
19
...
that I last saw h alive on. 19
and that death occurred, on the date stated above, at m.
If LESS than The CAUSE OF DEATH* was as follows:
* 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.)
Killed in action in
.
France
(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 ?.
(Signed)
.19
( Address)
M.D.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
St Joseph Cem. W. Rox.
DATE OF BURIAL
Sep. 12 1921
15 Filed Sep. 26. 19-2 1
Registrar of city or towa where death occurred
Filed
19
Registrar of city or towa where deceased resided
20 UNDERTAKER
J.7. 0 Maley
ADDRESS Winthrop
9. 25,000
1 PLACE OF DEATH France
County
.......
City or Town
2 FULL NAME
(a) Residence.
State
Mass
(Usual place of abode)
3 SEX
male
4 COLOR OR RACE
white
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
7 AGE
Years
Months
Days
29
6
29
If STILLBORN, enter that fact bere
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Soldier
(b) Name of employer
-
Dorchester
9 BIRTHPLACE (city or town) ...
PARENTS
14
Informant
Eliz a. miller
(Address)
of certificate.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
so that it may be properly classified. Exact statoment of OCCUPATION is very important. See instructions on back
(State or country)
Boston, Mass.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
single
6 DATE OF BIRTH (month, day, and year) apr. 1. 1889
1 day, ........ brs. or ....... mia.
10 NAME OF FATHER
Louis J. Miller
11 BIRTHPLACE OF FATHER (city or town)
Boston
(State or country) Mass.
12 MAIDEN NAME OF MOTHER Elizabeth a. Brenna
13 BIRTHPLACE OF MOTHER (city of town) Dorchester)
(State or country)
Boston Mass.
State
PERSONAL AND STATISTICAL PARTICULARS
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 ncedcd. 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," ctc., 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- cated thus: Farmer (retircd, 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 "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- eurrent) affection need not be stated unless important. Example: Measles (discase 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," etc., when a definite discase 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- 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 Medicai 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.
UNITED STATES GOVERNMENT WAR DEPARTMENT QUARTERMASTER CORPS GRAVES REGISTRATION SERVICE PIER 2, HOBOKEN, N. J .
CEP THEIR Ist 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 ... WITHTROP MALLACHUS DATA. AND SOLDIER ESCORT IS HEREBY AUTHORIZED TO ACCOMPANY SAID BODY IN TRANSIT.
FULL NAME OF DECEASED MILLER William Pfc. 62903
K.G.Co.101st Inf.
CAUSE OF DEATH KA
DATE OF DEATH 10-30-18
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 JERSEY, AND THE ISSUANCE OF THIS PERMIT HAS BEEN APPROVED BY THE SAID DEPARTMENT.
R. E. SHANNON, CAPTAIN, Q.M.C., U.S.A OFFICER IN CHARGE.
VI.
Oct. 30.1918
7
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
Chelsea
(City or town)
Registered No ....
1059
County
Suffolk
State
IS SS .
Registered No.
(Place of residence)
St ..
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Sylvester Horton
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State
Mass.
City or Town
Winthrop
No.
St.
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
days
How long in U. S., if of foreign birtb?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
„.idower
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Unknown
6 DATE OF BIRTH (month, day, and year)
Dec. 23, 1837
7 AGE
Years
80
Months
10
14
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
Organ Haker
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
(duration)
yrs ..
mos ..
12 d.
CONTRIBUTORY
(SECONDARY)
(duration)
yrs.
mos.
ds.
10 NAME OF FATHER
John Horton
18 Where was disease contracted
if not at piace of death ?
-
Did an operation precede death ?.
NO
Was there an autopsy ?.
What test confirmed diagnosis ?.
(Signed)
Samuel W. Crittenden
M.D.
-- ,19
(Address)
Soldiers' Home Chelsea
14
Informant
Records of Soldiers' Home
(Address)
Chelseas
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Winthrop Cem.
DATE OF BURIAL
Nov.10
19
18
15 Filed .. NOV.9 , 1918.
Registrar of city or town where death occurred
Filed
19 X
Registrar of city or town where deceased resided
16 DATE OF DEATH (month, day, and year)
Nov. 7
19 18
17
I HEREBY CERTIFY, That I attended deceased
from
June
18
Nov. 7
18
19
to
19
that I last saw h .......... In alive on
NO .....
19.1.8.,
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows:
*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.)
Cerebral Hero rhage
9 BIRTHPLACE (city or town)
Orlear s
(State or country)
Mass
PARENTS
11 BIRTHPLACE OF FATHER (city or town).Fastham
(State or country)
Lia ss .
12 MAIDEN NAME OF MOTHER Elizabeth Could
13 BIRTHPLACE OF MOTHER (city or town)
East ham
(State or country)
Mass.
of certificate.
Days
If LESS than
If STILLBORN, enter that fact bere
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,
1 PLACE OF DEATH
(Place of death)
City or Town
Chelsea
No.
Soldiers' Home
20. UNDERTAKER
W.C.Skaggs
ADDRESS
Winthrop
Date of
nov
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 mna- 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, ete. Women at home, who are engaged in the duties of the househokl 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, cte. 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 inay be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nonc.
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