USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 19
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Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATHI (the primary affection with respect to time and eausation), 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, peritonacum, etc., Careinoma, Sar- eoma, etc., of. ......... .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles; Whooping cough; Chronie valvular heart discase; Chronie interstitial nephritis, ete. 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," "Shoek," "Uraemia," "Weakness," cte., when a definite disease can be aseertained as the cause. Always qualify all discases 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 violenec, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homieidc, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, ete.
. 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. 35 Perkus St. ...... Ward)
(City or town [If death occurred in e hospitel or institution, give its NAME instead of street and number.]
2 FULL NAME ano Keene Saule
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE BS Perkus, Wrulling
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
urban
6 DATE OF BIRTH Self 6 1842 -.. (Month) (Day)
7 AGE
If LESS than I day, ....... hrs.
mos.
ds.
or ....... min. ?
8 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)
Duxbury Mass
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Marshfield Mars
12 MAIDEN NAME OF MOTHER Ruit Partridge
13 BIRTHPLACE OF MOTHER (State or country)
marshfield mans
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informent)
C.R. 13 enson
(Address)
Filed ............ , 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
.... 191 ....
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
national Cameo
mle heave decine -
(coman
Sclerosis ?) -
(Sudden codice the )
mos ..
...........
ds.
Contributory
(SECONDARY)
(Duration)
yrs.
.mos. ............
ds.
(Signed)
Bongas Magomedo,
(Address)
11.20 pm
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
.8 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
.. yrs.
In the
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 Hanover Mars
DO UNDERTAKER
CR Bensusan
DATE OF BURIAL
6/16
·
1917
ADDRESS
M.D.
10 NAME OF
FATHER
Patia Keene
7866
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
Registered No.
1
(Year)
y 14/1916
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 eachı 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," "Forcman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborcr, Laborer - Coal mine, etc. 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 employcd, 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, Houscmaid, 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 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: 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., 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; Chronic interstitial nephritis, ctc. 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" (mcrely 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 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 cf 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
Winthrop
(No.
83. Rever Pour
St. :
....
Ward)
....
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Partie. Trefla
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
83 River Road Winches Man
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
& SEX
male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
-
Manud
· DATE OF BIRTH
-
(Month)
(Day)
(Year)
If LESS than
1 day ......... hrs.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
.Mangun
(b) General nature of industry.
business, or establishment In
which employed (or employer)
Paper block
9 BIRTHPLACE
(State or country)
18 angor me
PARENTS
12 MAIDEN NAME
OF MOTHER
Harriet Sylvester
1ª BIRTHPLACE OF MOTHER (State or country}
Nord gewerk me.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Marquect- K. Duplo/wife
(Address)
82 River Rd
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH~
111 ay
(Month)
15
1916 (Year)
17
I HEREBY CERTIFY that I attended deceased from
1916
to
Truy 15
1916
that I last saw h.
Lalive on
muy 13
191
6 and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows :
.. (Duration)
... yrs.
.......
mos.
10
ds.
Contributory
Carcinoma of Stomach
(SECONDARY)
(Duration)
„yrs.
mos. ds.
(Signed)
....
Stary alteel
M.D.
.
May 17 1916 (Address)
200 Pleasant
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.
ds.
State ............ yrs.
........
In the
... mos. . ....... ds .............. Where was disease contracted, if not at place of death ?.. Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Forest Hill Camely
DATE OF BURIAL
5/17
1916
20 UNDERTAKER
C.RBinusm
ADDRESS
(Day)
1
...
7 AGE Probably 52 years
...
10 NAME OF
FATHER
John Wheeler Tufts
11 BIRTHPLACE OF FATHER (State or country)
.......
8 15/1916
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 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) Grocery; (a) Forcman, (b) Automobile factory. The material worked on inay 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 dutics 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 occu- pation whatever, write None.
-
1
-
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 saine disease. Examples: Cercbro-spinal fcvcr (the only clefinite 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., Careinoma, 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 necd 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- 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 discase can be ascertained as the cause. Always qualify all discases 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, Homieidc, 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 strcet, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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.
PARENTS
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
Charlotte Town .
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
wocheel man
.
REGISTRAR
..
C
(Month)
(Day)
(Year)
· DATE OF BIRTH
april 18 -
18471.
(Month)
(Day)
7 AGE
If LESS than 1 day ........ hrs.
or ....... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)
17 I HEREBY CERTIFY that I attended deceased from
(Year)
may 115
.....
1916, to
May 175
191
6
that I last saw her alive on
may 175
, 19!
6
and that death occurred, on the date stated above, at
11P m.
The CAUSE OF DEATH* was as follows : Pneumonia (Solar)
arteriosclerosis Hypertrophy & Dilatation di heart
(Duration)
.yrs.
.. mos.
7
.ds.
las above
Contributory.
(SECONDARY)
(Duration)
yrs.
mos. ds.
.......
(Signed)
Horace Soule M 2
M.D.
May 160
1916 (Address)
180 H cather So, Wintheway,
5.00
* 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.
Where was disease contracted, If not at place of death ?.
Former or usual residence ...
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
5/24, 191.
..... .
ADDRESS
16 Filed
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
......
(No.
Rear 37 Sammysich Uster
Ward)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Soha Richard Pulman
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manuel
16 DATE OF DEATH
man
17
1916
69 yrs.
.yrs.
0
mos.
ds.
9 BIRTHPLACE
(State or country)
Charlotte Town P.S.C.
10 NAME OF
FATHER
am Puliaño
11 BIRTHPLACE OF FATHER (State of country) England
191
20 UNDERTAKER
l' R. Penso
(City or town.)
17,1916
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- 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, ete. 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 domestic service for wages, as Servant, Cook, Housemaid, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oecu- 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 "Epidemie 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., Carcinoma, Sar- coma, etc., of ... ..... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie 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 .; Broneho-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," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., 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.
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. Deatlıs 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.
-
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 Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winther Han (No 50 Sagamme an
St. ;.................... .... Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Elizabach- Hanson
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.]
with of alongo Nameon
@RESIDENCE
50 Sagamore are Wunschit
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
may
6
(Month)
(Day) 20
191 (Year)
6
17
I HEREBY CERTIFY that I attended deceased from
april 23
, 1916
, to,
Lucy 20
191
that I last saw h ......... alive on
may 16
6
.
191
and that death occurred, on the date stated above, at
625 Cm.
The CAUSE OF DEATH* was as follows :
arterio scleroses
Sexual
(Duration) ............... yrs. ................ mos. ................ ds.
Contributory. (SECONDARY)
(Duration) yrs. mos. .............. ds.
(Signed)
M.D.
May 22, 1916
(Address)
U fintup
* 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.
ds .............
Where was disease contracted,
if not at place of death ?
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Partant me
DATE OF BURIAL
5/224 1916
20 UNDERTAKER
ADDRESS
Filed 191
REGISTRAR
7 AGE
If LESS than
I day ......... hrs.
.. yrs.
>
.mos.
10
ds.
or ........ min. ?
& OCCUPATION
(a) Trede, profession, or
particuler kind of work
(b) General nature of Industry, business, or establishment which employed (or employer).
9 BIRTHPLACE
(State or country)
Lecustos me
10 NAME OF
FATHER
Ellini Sawyer
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16
(Day)
1841
1
(Year)
· DATE OF BIRTH
Oct 10
-
(Month)
.
PARENTS
Winthing
May 20 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 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, ete. 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) Automobilc 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 homc. 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 oecu- pation whatever, write Nonc.
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