USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 35
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4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15-8-'15. 100,000.
OCHHHLOWW
HAH
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1916.
CITY OF BOSTON.
FULL NAME
SUSAN STEVENSON
Registered No.
10246
Place of Death ¿ and Residence
Boston
PSYCHOPATHIC HOSPT.
Date of Death
OCT. 19
1916.
Age
82
years
7
months
29
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
M
CLARK
Maiden Name
CHARLES E. STEVENSON
Husband's Name
Birthplace
WINTHROP
Name of Father NATHAN CLARK
Birthplace of Father
Maiden Name of Mother
Birthplace of Mother
-
Occupation HOUSEWIFE
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
1916,
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 :
ISTRAR'S
SICUT ( Duraton} Aus
FICE
CTVITAL
BOSTONIA CONDITAA.
IS REGIMIME DONATA A OSTO
I. MASS.
Contributory . ! (Duration)
SENILE DEMENTIA
(Signed) A.C.WELLINGTON M. D.
OCT .20 1916
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
WINTHROP (WINTHROP CEM
Usual Residence WINTHROP (12 -PRICE AVE)
Filed
OCT.23
1916.
Undertaker C.D.GRIMWOOD
A true copy.
Attest :
Emblemen
Registrar.
BRONCHO -PNEUMONIA - 9 DYS
CITY
Oct. 19 1916
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
II BIRTHPLACE
OF FATHER
(State or conntry)
(7) Icollant
12 MAIDEN NAME
OF MOTHER
Ina. D. Anques
1ª BIRTHPLACE
OF MOTHER
(State or country)
Scotland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Toka. H. Muito Gens
(Address)
459 Shirley St
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
Oct
6 (Month) 23d . 191_ ......
(Day)
(Year)
· DATE OF BIRTH
fiet
9 1909
(Month)
(Day)
1 (Year)
7 AGE
If LESS than I day ......... hrs.
yrs.
8
mos.
14
ds.
or
....... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
School Boy
(b) General nature of industry, business, or establishment In which employed (or employer).
anterior/ Poliomielitis
(Duration)
yrs. ................ mos.
ds.
Contributory
Pulmonary De deus
(SECONDARY)
.(Duration)
1
ds.
mos.
(Signed)
Irf. Part
.................
M.D.
Graf. 24, 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).
At place
of death.
. yrs.
In the
.. mos. ...........
ds.
State ............ yrs.
............ mos. ............ d.s ......
Where was disease contracted,
If not at place of death ?..
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
00-25
6
191
........
20 UNDERTAKER
ADDRESS
Wirellerote
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
Winthrop No 459 Shirley
St. ;..
Ward)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
John Sochard Merito
? FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
459 Shirley Sh Mucksoh
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Make
4 COLOR OR RACE
Mute
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
...
17 I HEREBY CERTIFY that I attended deceased from
to ...
22-
1916
Cet. 234
., 1916
that I last saw h ...
alive on
Oct. 2 2., 1916.
and that death occurred, on the date stated above, at 7-30cm
The CAUSE OF DEATH* was as follows :
3
9 BIRTHPLACE
(State or country)
Prove dena P, Q
13
10 NAME OF
FATHER
John . H.
(City or town.)
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 inaterial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dcaler," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestie serviee for wages, as Servant, Cook, Housemaid, ete. If the occupation has been ehanged 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 affeetion 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, ete., Carcinoma, Sar- coma, cte., of .. ...... „(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; Measles; 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 symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," cte.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be aseertained as the eause. 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 caused by violenee, 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 eireumstances 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
11 BIRTHPLACE OF FATHER (State or country) W'ashmeine D.C.
12 MAIDEN NAME
OF MOTHER
Elizabeth Bland
13 BIRTHPLACE OF MOTHER (State or country) Can. Va.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Benjamin Hall
(Address)
32 Perkins (27
Filed .. , 191 ....
REGISTRAR
...
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
femaci
4 COLOR OR RACE
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
131/16 1
... yrs. mos. 17 ds.
Or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work.
none.
(b) General nature of industry. business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
(Duration)
.......... yrs.
mos.
ds.
Contributory
(SECONDARY)
.(Duration) ........
... yrs.
mos. 5 ds.
(Signed)
Cel. 27, 1016
(Address)
......
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
In the
of death
yrs.
mos.
da.
State ............ yrs.
mos.
ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Mound Hoffe
DATE OF BURIAL
Cel 24. 1916
20 UNDERTAKER
Bem. V. Jones. 60%
ADDRESS
throw lo
Boston
....... .......
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthroto (No. 32 Perkins Lt
St. :
......... Ward)
Elmora-Hour
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of busband.]
.....
@RESIDENCE
32 Tilling Street
Registered No.
16 DATE OF DEATH
(Month) 27 .... 1916. (Year)
· DATE OF BIRTH
Octobre
(Month)
(Day)
(Year)
? AGE
If LESS than 1 day ......... hrs.
17 I HEREBY CERTIFY that I attended deceased from Och, 26, 1916 to Och, 27, 1916 .... that I last saw her alive on Och, 27, 1916, and that death occurred, on the date stated above, at 119.m. The CAUSE OF DEATH* was as follows :
Browcho- Aucuna
1
ca -.
Did a surgical operation precede death ? Lo, Date
10 NAME OF
FATHER
Benjamin Have"
M.D.
BOSTON ... .......
(Dáy)
...... .
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 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- motivc 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 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 Doy laborcr, Farm laborer, Laborer - Coal mine, ete. 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 oceu- 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 heort diseosc; Chronic interstitial nephritis, cte. 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 terininal 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, Gos poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminol abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized discase, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should stato CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
[10-'16-XXM.]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop ...
( No
435 Winthrop
St. :
„Ward)
2 FULL NAME
Thomas picker
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 435 Winthrop At Winthuh
Registered No.
MEDICAL CERTIFICATE OF DEATH
3 SEX
' COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED.
OR DIVORCED
(Write the word)
Widowed
" DATE OF BIRTH
(Month)
(Day)
(Year)
" AGE
If LESS than I day ......... hrs.
70 yrs.
mos.
.dg.
or ........ min. ?
S OCCUPATION
(a) Trade, profession, or
particular kind of work
Re-Tired
(b) General nature of industry,
business, or establishment in
which employed (or employer)
OuTired Fisherman
9 BIRTHPLACE
(State or country)
Ireland
PARENTS
10 NAME OF
FATHER
Thomas Hickey
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Linknon
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs Catherine Herbert
(Address)
319 Winthrop It With
16
Filed , 191
REGISTRAR
-18 DATE OF DEATH
...
(Month)
(Day)
191. (Year)
....
17 I HEREBY CERTIFY that I attended deceased from to Qcx28 1916 Nav 4 1916 I Dom. . . .
that I last saw h 221 alive on Nov 4 1916 .... and that death occurred, on the date stated above, at. 1130m am. The CAUSE OF DEATH* was as follows :
Indivia's Lingina
Did a surgical operation precede/death ? Date
(Duration) ........ yrs. .........
mos.
>
ds.
Contributery
Clinic Endocarditis
............. yrs.
........
mos.
de.
(Signed)
1/626
191.6 ... (Address) .................
M.D.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
........ yrs.
.. mos ..
.......
In the
„ds.
State
... yrs.
mos. ...... ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Holy Cross Maldad Nov of the
6
20 UNDERTAKER KEEP 9 M Cardle
ADDRESS
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
BOSTON .....
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
., 1
........
RECORD
200. 4.1916
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) Salcs- man, (b) Grocery; (a) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definito 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, IIouscmaid, 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 bo indicated thus: Farmer (retired, 6 yrs.). For persons who have no oecu- pation whatever, write None.
Statement of cause of death. - Name, first, tho DIS- EASE CAUSING DEATH (tho primary affection with respect to time and causation), using always the samo accepted term for the samo disease. Examples: Cerebro-spinal fever (tho 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, cte., Carcinoma, Sar- coma, etc., of .(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles; 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: Mcasles (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," "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 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, IHomicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized discase, as A death upon the street, or one supposed to be due to Alcoholism, etc
4. Deaths under circumstances unknown, as A person found dcad, etc.
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. 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
' PLACE OF DEATH Nicht Mas No 25 Someach are
......
feny or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Ernes & Luther 2 FULL NAME [ If married or divorced woman or widow give maiden name, also name of husband.] ....... @RESIDENCE 25 Somment are Ureth Registered No.
PERSONAL AND STATISTICAL PARTICULARS
J SEX
Mall
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Marsul
* DATE OF BIRTH
...
(Month)
(Day)
(Year)
1 AGE
76
.yrs.
5
mos.
6
ds.
If LESS than
I 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).
9 BIRTHPLACE
(State or country)
England
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
11
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address) Withical st.
16 Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
.
...........
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from 1915 191 .. to 1916 that I last saw h hi alive on Nov 4 2 1916 and that death occurred, on the date stated above, at 5 Am. The CAUSE OF DEATH* was as follows :
General areno actions
afroflex w
(Duration)
1 yrs.
.yrs.
......... .. mos. ............. ds.
Contributory.
(SECONDARY)
(Duration)
.yrs.
„mos. ................ ds.
(Signed)
,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).
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
18 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
200 8
1916
...
20 UNDERTAKER
ADDRESS
M.D.
PARENTS
Ward)
1916
1-18kg
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 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, ete. 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 occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- CASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," 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 neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age,". "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the eause. Always qualify all diseases resulting from ehildbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
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