USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 29
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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.
L
,
:
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH 1916.
CITY OF BOSTON.
FULL NAME
RICHARD WILCOX
Registered No. 7697
Place of Death l
Boston
and Residence
Date of Death
AUG.2
1916.
Age
35
years
months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
M
Maiden Name
Husband's Name
BOSTON
Birthplace
Name of Father
JOHN WILCOX
Birthplace
of Father
ENGLAND
Maiden Name of Mother
JANE MILBANK
Birthplace of Mother
IRELAND
Occupation
PRINTER
Informant
Place of Burial or removal
CEDAR GROVE
Undertaker R.& E.F.GLEASON
PHYSICIAN'S CERTIFICATE.
1916, I HEREBY CERTIFY that I attended deceased during last illness, from 1916, to that to the best of my knowledge and belief death occurred, on the date stated above, and that the CAUSE OF DEATH was as follows :
RAR'S
PA
RIBIS SIT DRE Primaro (Durator
CITY
OFFICE
MENINGITIS -FROM ACUTE EAR 2 DYS (OPR.JULY 31.1916)
CTV BOSTDNIA CONDITAA
1 0. 1822.
SREGIMIME DONATA A
TO
N.
AC.ABSCESS IN EAR - 16 DYS
(Signed)
L.E. WHITE
M.D.
AUG.2
1916
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Usual Residence
WINTHROP (87 SHORE DRIVE)
Filed
AUG.4
1916.
A true copy.
Attest :
Registrar.
BAY STATE HOSPT.
İ
MASS.
Contributory . (Duration)
aug. 2, 1416
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
.........
1 PLACE OF DEATH
(No. 51 Palmyra St. :
...... .. Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
/ (Month)
2
(Day)
191
(Year)
I HEREBY CERTIFY that I attended deceased from
6
Juan
11
1916
2
191
to
that 1 last saw h2
alive on
aug 2
191.
and that death occurred, on the date stated above, at.
.
9.30An.
The CAUSE OF DEATH* was as follows :
Sarcoma
A 13 rains. (las)
(Duration)
.......
.... yrs.
4 + mos
ds.
Contributory
(SECONDARY)
(Duration)
.yrs.
mos.
ds.
RM Paker
,
M.D.
(Signed)
3
, 191
6
........
(Address).
Withinof mars
* 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 ............ yri. ...
mos.
In the
.......... ..............
Where was disease contracted,
If not at place of death ?.
Former or usual residence ...
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Rug 4, 196
20 UNDERTAKER
W.C. Skaggs
ADDRESS
Winthrop
$ SEX
· DATE OF BIRTH
.
7 AGE
* OCCUPATION
(a) Trade, profession, or
particular kind of work
PARENTS
WRITE PLAINLT, WITHT ONFADING INK - THIS IS A PERMANENT RECORD.
(b) General nature of industry,
business, or establishment in
which employed (or employer)
COLOR OR RACE
W
· SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Manuel
1879 17
(Year)
If LESS than
I day ......... hrs.
37
.yrs.
6
mos.
6 ds.
ds.
or ........ min. ?
C
9 BIRTHPLACE
(State or country
Sales. Ing.
10 NAME OF
FATHER
Joseph Sawyer-
11 BIRTHPLACE
OF FATHER
(State or country)
Duchan Ec
12 MAIDEN NAME
OF MOTHER
Hannie E. Banga.
13 BIRTHPLACE
OF MOTHER
(State or country)
maine
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Samuel l. Doane
(Address)
51 Palmira St
m
16
Filed
, 191.
REGISTRAR
Evelyn L. Doane
2 FULL NAME
[If married or divorced woman of widow give maiden name, also name of husband.I Savoyen- 8.9.20ans @ RESIDENCE 51 Palmina St. Winthrop .... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
/
(Month)
26
(Day)
6
......
...........
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- 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, 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," 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 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 "Epidemie ecrebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobor 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: Meosles (disease eausing 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 eause. 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, Homicide, etc.
2. Deaths supposedly eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, E.c- 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 deod, 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 classifled. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH 39 Seafoaux Onne Hintlust Has
...... ......
Mutuof. BOSTON
(City or town.)
Ward) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Oven M. Gilles
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
61
Es preso Se Brooklin
............. Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Mal
* COLOR OR RACE
Intento
& SINGLE,
MARRIED,
WIDOWED
LOR DIVORCED
(Write the Name
· DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
65.
... yrs.
mos.
......
.....
or ........ min. ?
* OCCUPATION
(a) Trade, profession,
particular kind of work
Liquor Dealer
.........
(b) General nature of industry, business, or establishment in which employed (or emplayer).
& BIRTHPLACE
(State or country
Island
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
Lucknow
"THE ABOVE IS, TRUE TO THE BEST OF MY KNOWLEDGE
Glace
(Informant
(Address) 161 Centre de
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
....
17
I HEREBY CERTIFY that I attended deceased from
June
29
....... , 191 ....... , to
....
1916
that I last saw h ....... alive on
any
191
6 ..... and that death occurred, on the date stated above, at. 11:30 pm.
The CAUSE OF DEATH* was as follows : Ofration for Cancer of Rectum artificial amus - aful 11, 1916.
A Did a surgical operation precede death ?
Date
Carcinoma y Rection
yrs. ............... mos.
ds.
Contributory
(SECONDARY)
.. (Duration)
yrs.
mos. ............
ds.
(Signed)
Bruj & Sibles
M.D.
Duy 5 , 1916 (Address)1595 Bram Is Publice
* 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 dlsease contracted,
If not at place of death ?.
Former or usual residence
DATE OF BURIAL
D UNDERTAKER
ADDRESS
Filed 191
,
-
16 DATE OF DEATH
Croquet
(Month)
H
. 196
.....
.......
(Day)
(Year)
If LESS than
I day ......... hrs.
Ids.
........
important. See Instructions on back of certificate.
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
19 PLACE OF BURIAL OR REMOVAL I foly Como Malden
......
10 NAME OF
FATHER
7 f
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 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 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 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 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 disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- 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; 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" (mcrely 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 deathis of persons not disabled by recognized discasc, 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-XXM ]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No 25 Belcher St
St. ;.............. Ward)
Winthrop BOSTON
......
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
? FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 25 Belcher St
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
# SEX
4 COLOR OR RACE
Female Ichite
5 SINGLE,
Single
MARRIED, WIDOWED, OR DIVORCED (Write the word)
· DATE OF BIRTH July 24th, 916 (Month) (Dây) (Year)
7 AGE
If LESS than ! day ......... hrs.
yrs.
mos.
11
ds.
or
... min. ?
* OCCUPATION
Fattura- Letter Carrier
(b) General nature of industry, business, or establishment which employed (or employer).
9 BIRTHPLACE
(State or country)
Winthrop Mars
PARENTS
12 MAIDEN NAME
OF MOTHER
Mary E. Kirley
18 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
John I. Forristall
(Address) 25 Belcher St
16
Filed 191 .......
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
6
1916
(Year)
17 I HEREBY CERTIFY that I attended deceased from July 27
, 1916, to
Que 6
6
....
191 ..... that I last saw her alive on 191 Guy 6 ........ and that death occurred, on the date stated above, at .m. The CAUSE OF DEATH* was as follows :
Premature birth
Did a surgical operation precede death ?
Date
(Duration)
.............. yrs. ................ mos. ................ ds.
Contributory. (SECONDARY) ....
.(Duration)
......
.yrs.
......
.mos. .............
ds.
(Signed)
Edward
M.D.
Guy 7, 1916
....... .
.........
(Address)
68 Paris SV .
* 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.
.......
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Holy Cross
DATE OF BURIAL
Aug 4 In 19
6
20 UNDERTAKER
ADDRESS
M. J. Kelly 11 Meridian or
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
10 NAME OF
FATHER
John &. Forristall
11 BIRTHPLACE
OF FATHER
(State or country)
Boston Mass
(a) Trade, profession, or
particular kind of work
Agnes Ruth Forristall
aug. 6 , 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 enginecr, 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 laborcr, Farm laborer, Laborer - Coal mine, etc ..... Women at home, who are engaged in the duties of the household only (not paid House- keepcrs 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," 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; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced 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 discase 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.
-
R. 15-8-'15. 100,000. . .
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.
:12-15-XXMI|
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Winthrop, Mais
20
Parkins
(No ....
......
BOSTON -
1 PLACE, OF DEATH
Mary G. Sullivan
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Kelly window of Patrick 2-Sullivan
57 Charlotte &t forchetta). Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
august
(Month)
(Day)
7
, 191 (Year)
17
I HEREBY CERTIFY that I attended deceased from
July 31, 1916,
to
aug. 2. 1916
that I last saw ha alive on
....
· and that death occurred, on the date stated above, at /O. J.m. The CAUSE OF DEATH* was as follows : Iyoranditis
yhostatic pneumonia
Did a surgical operation precede death ?
Date
(Duration)
.............. yrs. ............... mos. ................ ds.
....
10 NAME OF
FATHER
-Heller
David Sulfina
PARENTS
12 MAIDEN NAME
OF MOTHER
Catherine In- Carthy
13 BIRTHPLACE
OF MOTHER
(State or country)
refare
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Sullivan
(Address)
20 Testing 11
Filed
191
REGISTRAR
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death ..........
.. yrs.
mos. ..
ds.
State ............ yrs. ............ mos.
......
ds ..
In the
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Calvary
DATE OF BURIAL
Aug. 10, 1916
20 UNDERTAKER
Chas G. Coffers &Son
ADDRESS,
28 Savin Hillary
10
Sorchester mudr
1& SEX
Firmala
4 COLOR OR RACE
Arhite
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
17
........
(Ďay)
(Year)
7 AGE
If LESS than
1 day ......... hrs.
or ... .... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Al-Roma
(b) General nature of industry, business, or establishment which employed (or employer).
9 BIRTHPLACE
(State or country)
Boston Mass
Contributory
(SECONDARY)
.(Duration)
... yrs.
mos. ................ d ..
(Signed)
Charles + mahoney .
aug. 7. 1916 (Address) 356 Winthrop
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
Cimbalmer John H. Colfer
St. :
......... Ward)
(City or town.) [If death occurred in a hospital or institution, givo its NAME instead of street and number.]
$ DATE OF BIRTH
March
....
(Month)
67
...... rs.
4 mos.
15 ds.
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
ang. 7, 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, 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," 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 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 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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