USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 17
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Statement of cause of death. - Namc, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for tho 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," unqualificd, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, etc., Careinoma, Sar- coma, 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 (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," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ctc., when a definite disease can be ascertaincd as the causc. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL scpticaemia," "PUERPERAL peritonitis," etc. 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, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ete.
3. Sudden deathis of persons not disabled by recognized disease, as A death upon the street, or onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
[12-'15-XXM.]
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop. (No. 43 Lewis Ave. .......
Winthrop
(City or town.)
[If death occurred in e hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Christina E.Kitson .wifeofHollis .... 0. 43 Lewis Ave. Winthrop.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
female
4 COLOR OR RACE
white
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCEDmarried.
(Write the word)
16 DATE OF DEATH
May 2 1916
191
(Month)
(Day)
(Year)
· DATE OF BIRTH
July 8 1877.
(Month)
(Day)
(Year)
If LESS then
[ day ......... hrs.
or ......... min. ?
$ OCCUPATION (a) Trade, profession, or particular kind of work
(b) Generel nature of Industry, business, or establishment in which employed (or employer) ..
Endocarditis
Did a surgical operation precede death ? Date
(Duration)
.... yrs. mos. ds.
Contributory.
aceite nephritis
...
(SECONDARY)
(Duration)
2
.... yrs.
mos. .... ............. ds.
MR. Partir
M.D.
May 3, 16 ...
(Address)
Wenthurt, Mais
* 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 diseaso contracted, If not at place of death 7.
Former of usual residence
19 PLACE OF BURIAL OR REMOVAL Winthrop Cem.
DATE OF BURIAL
4/5/
191 ~~
20 UNDERTAKER
srbaus.
ADDRESS
Bartin
7 AGE PARENTS important. See instructions on back of certificate. 15 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 .....
9 BIRTHPLACE
(State or country)
Roxbury Mass
10 NAME OF
FATHER
Isaac Kitson
11 BIRTHPLACE
OF FATHER
(State or countryr land.
12 MAIDEN NAME
OF MOTHER
Mary A.Cumming
18 BIRTHPLACE
OF MOTHER
(State or country)
Scotland.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
H. O. Thomas.
(Address)
42 Lewis Ave.
Filed _, 191
....
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
...... .
15 to.
May 2 d
..
that I last saw her
alive on
Mod 2d
...
1914.
38
9
mos.
24
ds.
1914.
and that death occurred, on the date stated above, at
65
„.m.
The CAUSE OF DEATH* was as follows :
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
Christina E. Thomas.
St. ;
......... .Ward)
(Signed)
............
may 2 , 1916
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 caclı and every person, irrespective of agc. 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 linc is provided for the latter statement; it should be used only when needed. As cxamples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (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 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 indicated tlius: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
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 diseasc. 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; Broneho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonaeum, etc., Careinoma, Sar- coma, etc., of ... .......... ........... (name origin: "Cancer" is Icss definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (mcrcly 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 causc. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia,". "PUERPERAL peritonitis," etc. 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, etc.
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 dead, etc.
+
R. 15-8-'15. 100,000.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See Instructions on back of certificate.
The Commmwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
' PLACE OF DEATH
( No.
7/
Winthrop
St. ............ Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
៛ COLOR OR RACE
w
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
* DATE OF BIRTH
6
2
1868
17
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day ......... hrs.
52
...... yrs.
11 mos.
2 ds.
or ....... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Winthrop
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
floyd.
13 BIRTHPLACE
OF MOTHER
(State or country)
Winthrop
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ..
Freda. whethermove
(Address) 71 Winthrop St.
16
Filed 191
REGISTRAR ....
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
5-
1916
......
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
Sept. 20
1913
......
to, ,1916. that I last saw ber alive on 1916. and that death occurred, on the date stated above, at9-301m. The CAUSE OF DEATH* was as follows :
(Duration) 2%
............... yrs.
.. mos. ...................
Contributory.
(SECONDARY)
(Signed)
Swill
(Duration) mos. ......... ....... yrs. ds.
.......... M.D.
Zané, 1915
(Addres)202
* 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 Winthrop cent,
DATE OF BURIAL
5- 7- 1916
20 UNDERTAKER
W.C. Ska990
ADDRESS
Willnote
2 FULL NAME
Clara S. Whitemore
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Winthrop
chanson
R.Floyd-Hned, a, Whittenone ....
Registered No.
(City or town.)
.....
Proquació paralizar).
10 NAME OF
FATHER
albert Richardson
a
4 /1/6 1
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthifulness of various pursuits can be known. The question applies to caclı 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, Architect, Loco- motive engineer, Civil engineer, Stationary fircman, ctc. But in many eases, especially in industrial employments, it i; 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) Grocery; (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 minc, etc. Women at home, who are engaged in the duties of the household only (not paid Housc- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employcd, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation lias 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 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- CASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Ccrebro-spinal fcver (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid usc of "Croup"); Typhoid fcvcr (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, 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 (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (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," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. 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, etc.
2. Deaths supposedly eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, 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.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
man 5049 1 PLACE OF DEATH
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(No. 69 Custar.
St. : Ward)
Watson C. Wade
? FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband .!
@RESIDENCE
39 Cust QUE. Wieluofer.
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
: SEX
· COLOR OR RACE
W
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
Windows
$ DATE OF BIRTH
8 18
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day ......... hrs ..
ds. or ....... min. ?
· OCCUPATION
Builder-
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
(3) Bellassle U.S.
10 NAME OF
FATHER
John M. Wade
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
Julia a. Miller
13 BIRTHPLACE
OF MOTHER
(State or country)
U.S.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
gus. Oscar Howett
(Address)
59 custavi.
.......... REGISTRAR
...
..
, 847
17
I HEREBY CERTIFY that I attended deceased from
1916 to
may 14
1916
....
that I last saw h.d .....
alive on
Zwang 13
1916
and that death occurred, on the date stated above, a
2 m.
The CAUSE OF DEATH* was as follows : Chimi myocarditis
(Duration)
yrs.
.mos.
ds.
......
Contributory Hayder Thanx + Rund paris copetin
(SECONDARY)
(Duration)
......
.yrs.
4 mos. .... ds.
(Signed)
may 16
., 1916 (Address).
218 March Quetil
... .
M.D.
* 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 Winthrop Cure.
DATE OF BURIAL
5-17.
1916
20 UNDERTAKER W.C. SKaggo
ADDRESS
Winthrope_
16 Filed ., 191
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
may
5
(Month)
14
(Day)
1916
(Year)
68 yr
... yrs.
8
mos.
26
(a) Trade, profession, or
particular kind of work
PARENTS
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
.... Registered No.
5,1916
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oceu- 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, Architect, Loco- motive 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) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on inay form part of the sceond statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborcr - Coal minc, 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 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 indicated thus: Farmer (retired, 6 yrs.). For persons who have no oceu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- CASE 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 "Epidemie 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); Measles; Whooping cough; Chranic valvular heart disease; Chronic 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," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "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, etc.
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 onc supposed ta be duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A1 person found dead, etc.
The Commmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
....
(No ....
........
St. ;.................. .Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Elizabet Shepherd
[If married or divorced weman or widow
1
give maiden name, also name of husband.]
@RESIDENCE
170 bort Rd - Nulthof Man
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX,
4 COLOR OR RACE
Mute
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Senje
· DATE OF BIRTH
4
1904
(Month)
(Day)
(Year)
7 AGE
12
yrs. 3 mos. 3 ds.
or
min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
School Girl
(b) General nature of Industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Rock port the
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Rockport
12 MAIDEN NAME
OF MOTHER
Bertha With
18 BIRTHPLACE
OF MOTHER
(State or country)
Phil-Pa .
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
C.R. (Summen
(Address)
15
Filed
191
REGISTRAR ....
16 DATE OF DEATH
may
(Month)
7
, 1916
(Day)
......... (Year)
17
I HEREBY CERTIFY that I attended deceased from
april 30
1914
May 7
to
1916
that I last saw h/
alive on
1916,
and that death occurred, on the date stated above, at 11:31pm
The CAUSE OF DEATH* was as follows : mixed infection of Blood
(Strepto bloghelyreseus)
(Duration)
............ yrs.
mos.
7 de.
Contributory.
(SECONDARY)
(Duration)
.. yrs.
.......
.. mos. ..............
de.
(Signed)
(3) Chulae)
M.D.
May 8, 1916 (Address)
writing
* 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).
At place
of death
yrs.
mos.
7 de.
In the .
State
.yrs. ...........
mos.
ds ...
Where was disease contracted,
If not at place of death ?.
160 Cont RU Walthing
usual residence
160 Cant Rd wally
Former or
19 PLACE OF BURIAL OR REMOVAL Rockfort
DATE OF BURIAL
May
6
...
191
20 UNDERTAKER
C. R. Bennison
ADDRESS
Winter
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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.
...
If LESS than
I day ......... hrs.
may 7, 1916
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- pation is very important, so that the relative healthfulness of various pursuits ean 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, Architcet, Loco- motive engineer, Civil engineer, Stationary fireman, ete. But in many cases, especially in industrial employments, it is neecssary 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 nceded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (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, ctc. 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, 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 faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
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