USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 26
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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, ctc., of ... .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (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," "Uracmia," "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 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
tato Hospital (No meLooro
St. . Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME. Charles ". inn c [If married or divorced woman or widow give maiden name, also name of linsband.] @RESIDENCE Winthrop mars.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
50 yrs. 10 mos. .C.C ..... ds.
or ........ min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work relilect -neivoor
(b) General nature of industry,
business, or establishment in
which employed (or employer).
--
(Duration)
10
yrs.
.mos.
ds.
Contributory
(SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
Charles C. Wright
M.D.
Jul, G. 191.6. (Address) 2042020
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (I) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death -
yrs.
2
mos.
-
ds.
State
yrs.
In the
mos.
ds.
......
Where was disease contracted, If not at place of death ?.
Former or
usual residence.
Winthrop, Mans
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Hospital Records
(Address)
esthoro
15
Filed
2 191.0
anit.
16 DATE OF DEATH
July (Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I have investigated the death of the deceased. The CAUSE OF DEATH* was as follows :
Conoral Paresis
9 BIRTHPLACE
(State or country)
Albany N.Y.
10 NAME OF
FATHER
Frances 1. inno
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
Jaro H. Codrin
13 BIRTHPLACE
OF MOTHER
(State or country)
1.Y.
:9 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
inthrop Cem.
20 UNDERTAKER
W. C Skaggs
ADDRESS
"inthron
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
Catboro (City or town.)
Registered No.
776
MEDICAL CERTIFICATE OF DEATH
1916
If LESS than
I day, ........ hrs.
.
July 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, 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," "Dcaler," 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 thus: 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 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 ncoplasms) ; Mcasles; 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite discase can be ascertaincd as the cause. Always qualify all discascs 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 (c. 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 deathis 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.
R. 16-8.'13. 5,000.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See Instructions on back of certificate.
PARENTS
12 MAIDEN NAME
OF MOTHER
Catherine Wilay
1ª BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
wucheng
16
Filed 191
......
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
White
5 SINGLE, MARRIED WIDOWED OR DIVORCED (Write the word)
mannen
184%.
· DATE OF BIRTH Feb 25 (Month) (Day)
7 AGE
69 .. yrs.
4.12 mos.
ds. or ..... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
at Home
(b) General nature of industry, business, or establishment which employed (or employer).
9 BIRTHPLACE
(State or country)
Megland
.(Duration)
4
mos.
ds.
yrs.
Contributory
artrio sebiosis
(SECONDARY)
.. (Duration)
5 yrs.
„mos. ......... ds.
(Signed)
R. B. Puben
M.D.
July
8
.. 1916. (Address)
Wanthigh hans.
.............
* 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
7/4
1916
20 UNDERTAKER
E. R. Bunun.
ADDRESS
Wnicht
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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH manchiof (No. 36 Villa an
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Catherine. S. Mortimer
2 FULL NAME
wofo of Henry
mortener
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 36 Villa are mychef Registered No.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
(Month)
7
1916
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
(Year)
March
5
191.2 .. , to
7
191_6,
. ,
that I last saw h 2V
alive on
Anlay 7
1916. and that death occurred, on the date stated above, at 730 Am. The CAUSE OF DEATH* was as follows :
Cachal healing.
10 NAME OF
FATHER
David Barrister
11 BIRTHPLACE OF FATHER (State or country) England
If LESS than I day ........ hrs.
St. ;. Ward)
.....
July 7.1916
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precisc statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applics 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 cngincer, 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," 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 domestie 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 (rctircd, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Ccrcbro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, 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 ncoplasms) ; Measles; Whooping cough; Chronic valvular heart discasc; Chronie interstitial nephritis, ete. The contributory (second- ary or intercurrent) affection nced not be stated unless im- portant. Example: Measles (discasc causing death), 29 ds .; Broncho-pneumonia (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (mercly symptomatic), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhagc," "Inanition," "Marasmus," "Old agc," "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 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 diseasc, 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.
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
[12-15-XXMI
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH winthrop (No .. 2) Irident ave
Winthrop
BOSTON
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Leah mary Davidson
' FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband J @RESIDENCE 27 Suident ave.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
(Month) ninth 6
(Day)
191 (Year)
· DATE OF BIRTH
Jan
(Month)
(Day)
(Year)
7 AGE
6
mos.
5 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)
$ BIRTHPLACE
(State or country)
Chelsea
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Russia
12 MAIDEN NAME
OF MOTHER
Jeannie Newton
13 BIRTHPLACE OF MOTHER (State or country)
Russia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Father
(Address)
27 Trident ave
16
Filed 191.
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from alar 1916, to. SI 1916.
If LESS than
day
... hrs.
that I last saw her alive on.
July 19
.......
.. 1916.
and that death occurred, on the date stated above, at.0.300m.
The CAUSE OF DEATH* was as follows :
Loben Pneumonia
·
Did a surgical operation precede death ?
Date
.. (Duration) .....
.......
.yrs. ......
...... mos ..
...........
ds.
Contributory.
Inanition
(SECONDARY)
.(Duration)
... yrs. ..
2
mos.
......
ds.
(Signed)
alfred Davi Don
M.D.
Inlas 9, 1916 (Address).
Pahulser
* 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
......
In the
.. 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 Noturn Beth July 9 1916
20 UNDERTAKER Lacok Stavetsky ADDRESS
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See Instructions on back of certificate.
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
Female
4th
1910
.........
10 NAME OF
FATHER
alfred Davidson
St. ;.. Ward)
July 7,1916
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preeise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applics 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 Plantcr, 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) Groccry; (a) Forcman, (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, Laborcr - 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 Servant, Cook, Housemaid, etc. If the oceupation 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.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tubcr-
culosis of lungs, meninges, peritonacum, ete .; Carcinoma, Sar- coma, etc., of .. .(name origin: "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart disease; Chronic 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- acmia" (merely symptomatie), "Atrophy,", "Collapse,". "Coma," "Convulsions,". "Debility" ("Congenital," "Scnile," ete.), "Dropsy,", "Exhaustion," "Heart failure," "Haemorrhage," "Inanition,", "Marasmus," "Old age," "Shock," "Uraemia,", "Weakness," ete., when a definito discase ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or misearriage, as "PUER- PERAL septicacmia,", "PUERPERAL peritonitis," etc. State eause 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, 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, ete.
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.
important. See instructions on back of certificate. 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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
(No.
35. Willow are
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.j
Howard Wellington
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 35 20 cllow are Withregistered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
' COLOR OR RACE
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Mamul
$ DATE OF BIRTH
Left 14 1870,
(Month)
(Day)
If LESS than I day ......... hrs.
or min. ?
· OCCUPATION
(a) Trade, profession, or
particular kind of work
Restaurant
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
Eines. W.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Bughton-
12 MAIDEN NAME
OF MOTHER
Mary Gately
1ª BIRTHPLACE OF MOTHER (State or country)
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
15
Filed 191
............
REGISTRAR
16 DATE OF DEATH
(Month)
12.
... 1916
....
........
(Year)
17 I HEREBY CERTIFY that I attended deceased from
(Year)
July 6th
to
1916
Lady 1 2, 1916.
that I last saw blev alive on
Clelia 12, 1916.
and that death occurred, on the date stated above, at
3a.m.
The CAUSE OF DEATH* was as follows :
Paren chymateus Hephata
.........
Vuole .(Duration) .. yrs. . ....
mos.
ds.
Contributory.
Organic Start Dexcare,
(SECONDARY).
.(Duration) .
.........
.yrs.
.. mos. ........... ds.
(Signed)
1 2 Pares
M.D.
Kelly 13., 1916. (Address)
Wenttürk
* Ifdeath 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 RETIOMAL
DATE OF BURIAL 7/14 6
.....
191
ADDRESS
20 UNDERTAKER
en B.
Wanthet
(City or town.)
TAGE 45
10
yrs.
mos.
ds.
MEDICAL CERTIFICATE OF DEATH
(Day)
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 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 Housc- 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.
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