USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 18
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Statement of cause of death. - Namc, first, the DIS- EASE CAUSING DEATH (the primary affeetion with respect to time and causation), using always the same aeccpted 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, ete., 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 intereurrent) 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 symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite disease can be ascertained as the causc. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "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 one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, ete.
N. B. - Every item of information should be carefully supplied. 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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
Chelsea.
Moss.
(No. Soldiers' Home St. :.
........ Ward)
CHELSEA (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Charles W . Hall
[If married or divorced woman or widow
give maiden name, also name of husband. ]
@RESIDENCE
Winthrop, Mass.
Registered No. 304
PERSONAL AND STATISTICAL PARTICULARS
a SEX
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Wid.
16 DATE OF DEATH
May 9. 1916.
191
· DATE OF BIRTH
Male
NOV.
21
1 84 517
(Month)
(Day)
(Year)
7 AGE
72
.yrs.
5
mos.
18
ds
or ........ min. ?
B OCCUPATION
(a) Trade, profession, or
particular kind of work
Journalist
(b) General nature of industry, business, or establishment in which employed (or employer).
Pernicious Anemia
(Duration)
.. yrs. ...............
ds.
Contributory
(SLCONDARY)
(Duration)=
................ mos.
......
da.
(Signed)
Edward A. Coates, Jr.
M.D.
May 2.
......
:00
(Address)
Chelsea
* 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.
3
mos .** *
=ds. - Stato ............ yrs. ............ mos.
In the
Where was disease contracted,
If not at place of death ?.
usual residence.
.
Former or
Winthrop,
Mass.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
15 Filed May 11, 1916 -200 490
REGIST
MEDICAL CERTIFICATE OF DEATH
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
6
Feb. 9,
to
May 9, 1916,
191
that I last saw h .... i.m alive on ........... , 191 ... 6, and that death occurred, on the date stated above, at12 ... 15A The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
Chelsea, Mass.
10 NAME OF
FATHER
Isaac C. Hall
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Mass.
12 MAIDEN NAME
OF MOTHER
Susanna Ryler
13 BIRTHPLACE
OF MOTHER
(State or country)
Mass
1º PLACE OF BURIAL OR REMOVAL Winthrop Cen.
DATE OF BURIAL
Lav 11
..........
191.6
20 UNDERTAKER
C. R. Bennison
ADDRESS
Winthrop
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
....
If LESS than
! day ......... hrs.
may 9, 1916 16
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, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, ctc. 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 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 houschold 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 occu- 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 "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, menitijes, peritonaeum, 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: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mere)y 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 can 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 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.
HLED IN THE OFFICE CX THE CITY CLERK.
MAY 1 6 1916
R. 18.8'15. 5,000
M.
KEVERE, MASS
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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No. Wave way are St. Ward)
7857
urultrap (City or town,
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME man & Jay.
[If married or divorced woman or widow
give maiden name, also name of husband.]
Wife of Edward Fay
@RESIDENCE
& wave way are
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
White
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the wordMarried
6 DATE OF BIRTH
(Month)
(Day)
7 AGE
76 yrs.
ds.
or ......
min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work At Home
(b) General nature of industry, business, or establishment i which employed (or employer)
9 BIRTHPLACE
(State or country)
Treland
10 NAME OF
FATHER
John Harnell
PARENTS
12 MAIDEN NAME OF MOTHER
Mary Hackett
13 BIRTHPLACE OF MOTHER (State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Miss E. Tay
(Address)
Wave way ive Winthrop
16
Filed ...........___ , 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
May
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I have investigated the death of the deceased. The CAUSE OF DEATH* was as follows : Natural Causes, Cardio-renal disease .
(Sudden death)
(Duration).
............. yrs. ................ mos.
.........
ds.
Contributory. (SECONDARY)
......
(Duration)
yrs.
mos.
ds.
(Signed)
Lange Burgers Magnet
M.D.
Man 12 9016
(Addres
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATHI, or, in deaths from VIOLENT CAUSES, state (I) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or IIOMICIDAL.
8 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
.yrs.
mos.
........
In the
ds.
State.
.yrs.
mos.
ds
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
May 14
191
Holy Cross Malden
:0 UNDERTAKER
John F. O'Maley
ADDRESS
Winthror
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
Registered No.
191.
....
Female
1
(Year)
If LESS than
I day, ....... hrs.
11 BIRTHPLACE OF FATHER (State or country) Treland
ONICINIEI HOH
y 11/ 1416
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, Architect, 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) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., 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 DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who liave no occu- 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, 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, ete. 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," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State
cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, 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."
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. 16-8.'15. 5,000.
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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No.
36 Cancer LI.
St. ;..
............
Ward)
Sarah Emerson
Tucker
........
No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
white
6 SINGLE,
MARRIED,
WIDOWED.
OR DIVORCED
(Write the word)
Widow
$ DATE OF BIRTH
Jsem 6 1836
(Month)
(Day)
(Year)
7 AGE
If LESS than
[ day ........ hrs.
.80 .
....... yrs. mos. ds.
..........
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
all Home
(b) General nature of Industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Borlow-
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Bnlow
12 MAIDEN NAME
OF MOTHER
Sarah George
18 BIRTHPLACE
OF MOTHER
(State or country)
Dracul
mars
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
le Rões
(Address)
Wencheof Mass
16 Filed ..................... 19|
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
May 11, 1916, to
.....
may 12, 191.6 that I last saw her alive on 191. 6 and that death occurred, on the date stated above, at 2:15 AM The CAUSE OF DEATH* was as follows :
(Duration)
.. mos. ................ ds.
Contributory
(SECONDARY)
(Duration) ..
„yrs.
mos. . ds.
(Signed)
M.D.
tony 13
191 .... 6.
(Address)
* 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.
In the
.. mos.
ds.
State ............ y:s.
.......... mos.
.......... ds ...........
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
5/14
1916
20 UNDERTAKER
CR Bem
ADDRESS
(City or town.)
[If death occurred in a 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
Willow of Jonathan. M. Jucker
16 DATE OF DEATH
12
191
(Month)
(Day)
...... (Year)
............ yrs. ...............
10 NAME OF
FATHER
Form .Hewitt
9
12/1916
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 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, 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) Salcs- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Forcman," "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, Houscwork, 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 Scrvant, 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 (retircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
1
Statement of cause of death. - Name, first, tlc 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 fevcr (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, peritonacum, etc., Carcinoma, Sar- eoma, 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 nced not be stated unless im- portant. Example: Mcaslcs (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 discase can be ascertaincd as the cause. 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, Suicidc, 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 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 dcad, etc.
៛
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No
35 Perfum
St. ;.
.....
.Ward)
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
George
Caliman
Poule
[If married or divorced woman of widow give maiden name, also name of husband .! @RESIDENCE 35 Paliw So Muchnot Registered No.
PERSONAL AND STATISTICAL PARTICULARS
1 PLACE OF DEATH
2 FULL NAME
$ SEX
Male
7 AGE
(b) General nature of industry,
business, or establishment
in
which employed (or employer).
11 BIRTHPLACE
OF FATHER
(State or country)
PARENTS
1ª BIRTHPLACE
OF MOTHER
(State or country)
(Informant)
important. See Instructions on back of certificate.
16
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
......
....... yrs.
COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Manuel
1 (Year)
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Petunt
......
9 BIRTHPLACE
(State or country)
Rockland whass.
10 NAME OF
FATHER
Soule
12 MAIDEN NAME
OF MOTHER
Dranna. Reed Keine
"THE ABOVE IS TRUE TO THE BEST, OF MY KNOWLEDGE
(Address)
Nonchal Man
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
13
1916
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
to
1916
Man 13h
1916
....
that I last saw ha
alive on
may/12
...
1916 .....
and that death occurred, on the date stated above, at.
2Am.
The CAUSE OF DEATH* was as follows :
General arterio selemais
Intral sequrgitation
(Duration)
ds.
Contributory.
(SECONDARY)
(Duration)
„.yrs,
............. mos.
ds.
(Signed)
Duy 13, 1916
(Address)
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).
At place
In the
of death ........
.... yrs.
.mos. ............
ds.
State ............ yrs. ............ mos. ............ ds ......
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL , Tanova Mas
DATE OF BURIAL
5/15
1916
........
20 UNDERTAKER
G . R. Ben-
ADDRESS
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
* DATE OF BIRTH
12
(Month)
(Day)
1838
If LESS than
I day ......... hrs ..
77
10
mos.
1
ds.
y 13, 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 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, Compositor, Architeet, Loco- motive 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 which needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salcs- . man, (b) Groecry; (a) Forcman, (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 flomestie 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 faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oecu- pation whatever, write None.
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