USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 30
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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: 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., Carcinoma, Sar- coma, etc., of ...... ............... (name origin: “Cancer" is less definite; avoid usc of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage,". "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Wcakness," 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.
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.
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
Wencherol
...
(No.
52 Willnot
St. :
.................
,Ward)
George Navison Dakes
? FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
52 Winchell Street
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
Mute
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Massi
· DATE OF BIRTH
Oct 27
(Month)
(Day)
(Year)
If LESS than
{ day ......... hrs.
or ....... min. ?
Returned
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
Brewer me
10 NAME OF
FATHER
keith Oakes
11 BIRTHPLACE
OF FATHER
(State or country)
Harringforme
12 MAIDEN NAME
OF MOTHER
Marquette Nodadone
1ª BIRTHPLACE
OF MOTHER
(State or country)
Daniscollama
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
& R. Bemus-
(Address)
16
Filed 191
REGISTRAR
Indefinite
(Duration)
.ds.
mos.
yrs.
Contributory.
(SECONDARY)
(Duration)
...... yrs. ....
.......
mos.
2 ds.
M.D.
(Signed)
Guy 8
.. 1916 (Address) 218 harig nicht
* If death followed injury or violence the certificate of death must be mad out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
OBECENT RESIDENTS).
At place
In the
of death
........... yrs.
mos.
ds ............
............ mos.
ds.
State
......... yrs.
Where was disease contracted, If not at place of death ?. Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL MY auchan Camb
DATE OF BURIAL
auf 9
191 6
20 UNDERTAKER -
ADDRESS
i
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Registered No.
Y DATE OF DEATH
Cuz
191
......
(Month)
(Day)
....
L
(Year)
17 I HEREBY CERTIFY that I attended deceased from
1916 to
Cinq 7
...
1916.
that I last saw h.A ........ alive on
1916.
and that death occurred, on the date stated above, at 715 A.m.
The CAUSE OF DEATH* was as follows :
Cartesio Filerosis
76
... yrs. mos. ds.
I
(a) Trade, profession, or
particular kind of work
$ SEX Male 7 AGE & OCCUPATION PARENTS WRITE PLAINGT, WITTY ONFADING INK THIS IS A PERMANENT NEVOND. 9 BIRTHPLACE (State or country)
Wanted
1
1
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 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, 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, ctc. Women at home, wlio 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 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 "Epidemie 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, peritoneum, 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- acmia" (mcrely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmiorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., wlien a definite disease can be ascertaincd as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," "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. Deathis 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 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.
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
1 PLACE OF DEATH Uruthrop (No. 104, Bay View Que. St. : Ward) ....
Withrob (City or tofvn.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
.......
Mary Maria
Cliffa
adam & Cliffs
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 2 Hummwell For Medford war
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
$ SEX
Tuale
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
marques
$ DATE OF BIRTH
Cion
J
186317
(Month)
(Day)
(Year)
" AGE
51
.... yrs.
......... mos
7
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
Commall England
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country
Comwall England
12 MAIDEN NAME
OF MOTHER
Maria
Pakson
18 BIRTHPLACE
OF MOTHER
(State or country)
Commall England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mhrs. Watson Cleft
(Address)
104 Bay View are.
15
Filed
191 ......
REGISTRAR
16 DATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
Nov 14
1914
to
aug 8
1916
that I last saw halive on
1916
.......
and that death occurred, on the date stated above, at ...
m
The CAUSE OF DEATH* was as follows :
Cancer
7
auf
appendages.
1
... (Duration)
... yrs.
.......
.mos.
..........
ds.
Contributory.
(SECONDARY>
(Signed)
...
am 8
1916
0
(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).
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
Oak Grove free Fry
medford tuaco
DATE OF BURIAL
aug. 11, 1916
20 UNDERTAKER
Fredk A. Bralo
ADDRES
Maxford Tuas
-
1916 (Year)
(Month)
8
(Day)
.........
If LESS than
I day ......... hrs.
10 NAME OF
FATHER
Mark Bury
«{Duration)
I. Tahan
.... 4yrs.
mos. ..........
ds.
2FULL NAME
aug. 8, 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 fircman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when necded. 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- kcepers 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 homc. Care should be taken to report specifically the occupations of persons engaged in domestic 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 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: Ccrebro-spinal fevcr (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 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.
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 strcet, 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.
PARENTS 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. 16 N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state .
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop ......
(No.1.1 .... Prospect -. Av.o. . St. : ......... .. Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
COLOR OR RACE
White
$ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED Widowed
(Write the word)"
· DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day ........ hrs.
77
... yrs. mos.
ds.
or ....... min. ?
8 OCCUPATION
(a) Trede, profession, or
particular kind of work
Retired
(b) General nature of Industry, business, or establishment In which employed (or employer).
9 BIRTHPLACE
(State or country)
Ireland
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Unknown
1ª BIRTHPLACE
OF MOTHER
(State or country)
Treland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. C. Jolson
(Address)
11Prospect Ave.
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH any 13' , 1916
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from any
1916
Quy 13
1916.
to
that I last saw h - alive on
and 12
1916.
and that death occurred, on the date stated above, at 4, 40 Am.
The CAUSE OF DEATH* was as follows :
Chimie Interstitial hethatis
General cesterio selonsis
.(Duration)
1 yrs.
.............. mos. ................ ds.
Contributory
(SECONDARY)
(Signed)
any 13, 1916
(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).
In the
At place
of deeth
.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 Holy Cross Malden
DATE OF BURIAL
hug 161916
191
20 UNDERTAKER
John F. 0'Kaley
ADDRESS
Winthrop
1
2 FULL NAME
Stephen .... Grady.
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
11 Prospect Ave.
Winthrop
Male
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
(Duration)
yrs. ...
31 Metcal
.........
mos. ...
ds.
M.D.
aug 13, 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," 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 domestie service for wages, as Servant, Cook, Housemaid, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oceu- 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 eerebro-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, ete., 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) affeetion 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 ean be aseertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ete. 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, ete.
2. Deaths supposedly eaused 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, ete.
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.
PARENTS
12 MAIDEN NAME
OF MOTHER
Frances Clark.
18 BIRTHPLACE
OF MOTHER
(State or country)
Boston
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16 Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
.....
(Month)
16
, 1916
......
(Day)
(Year)
· DATE OF BIRTH
12
(Monthi)
(Day)
7 AGE
If LESS than
- day. „.hrs.
7 6yrs.
8
mos.
14 ds.
* OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired
(b) General nature of industry,
business, or establishment in
which employed (or employer).
That Regrabalaton & Candan Dilatati
-
(Duration) ................ yrs. ........ mos.
ds.
Contributory.
Ronal passini casection
.....
: (SECONDARY)
(Duration)
yrs.
Z .mos. ds.
(Signed)
M.D. 1
.....
.......... 1916 (Address)
218 mais Bully
......
C * 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.
Where was disease contracted,
......
mos. ......
ds .............
..
If not at place of death ?.
...
Former or
usual residence.
..
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
8-18 1916
20 UNDERTAKER
11.2.
It - 9,0
ADDRESS
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
Francis Es. Cutter-
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Ensley ala.
....
Registered No.
124
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
4 COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Mamed.
......
1 PLACE OF DEATH
(No. 4
......... .Ward)
......
2
..
1839
17
I HEREBY CERTIFY that I attended deceased from
₼
(Yeaf)
July 1 4 1916. 10
aux 14
1916
-
that I last saw h. A ....... alive on
196
„min. ?
and that death occurred, on the date stated above, at
5-301mm.
The CAUSE OF DEATH* was as follows :
-
9 BIRTHPLACE
(State or country)
Boston Mars
10 NAME OF
FATHER
C.C. Cutte
11 BIRTHPLACE
OF FATHER
(State or country)
Butt Boston
R
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oceu- 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, 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) 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 houseliold 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 serviee 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 (retircd, 6 yrs.). For persons who have no oecu- pation whatever, write None.
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