USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 37
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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 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" (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.
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)
Goland
12 MAIDEN NAME
OF MOTHER
Leah Shatira
1ª BIRTHPLACE
OF MOTHER
(State or country)
Poland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Sister
(Address)
n.Y.
191 196 Louis M. Hauff .........
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
nov. 9
1916
....
(Month)
(Day)
(Year)
" DATE OF BIRTH
aug. 15
(Month)
(Day)
7 AGE
48
yrs. ...
2
mos.
24
ds.
min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work ...
......
Salesman
which employed (or employer).
Store
.. (Duration)
1
yrs.
2
mos.
ds.
Contributory
(SECONDARY)
(Duration) .
.............. yrs.
.......
.. mos. ...............
„ds.
(Signed)
Geo, n. Lapham
M.D.
Nor. 9, 1916 (Address)
Rutland
* 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 -
3
mos.
16de.
In the
of death ............
.yrs
State ............ yrs.
.mos.
...........
Where was disease contracted,
if not at place of death ?.......
Former or
usual residence.
Nachrol mars
19 PLACE OF BURIAL OR REMOVAL
Boston
DATE OF BURIAL
nov. 11.
1916
16 nov. 10
Filed.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Cheltand
(No.
........................ ....
St. :
Ward)
Rutland (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Jacob Garner
[If married or divorced woman or widow
give maiden name, aleg name of husoand.]
@RESIDENCE
Winthrop, Mass.
Registered No.
65
PERSONAL AND STATISTICAL PARTICULARS
* SEX
male
' COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
, 1868
17
I HEREBY CERTIFY that I attended deceased from
(Year)
July 22, 1962 to
nov. 9
1916
.......
that I last saw him alive on
nov. 8
1916
and that death occurred, on the date stated above, at 10.40 am.
The CAUSE OF DEATH* was as follows :
Pulmonary tuberculosis
9 BIRTHPLACE
(State or country)
Baltimore
10 NAME OF
FATHER
Joseph
If LESS than
I day ........ hrs.
(b) General nature of industry,
business, or establishment
5.
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
20 UNDERTAKER
R. C. Prescott & Son
ADDRESS
Rusland
JIANUARU 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, c. 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 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, 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, etc. The contributory (second- ary or intercurrent) affection need not be stated unless iin- portant. Example: Mcasles (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," "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, 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 duc to Alcoholism, etc
4. Deaths under circumstances unknown, as A person found dead, etc.
-
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD: CERTIFICATE OF DEATH
1 PLACE OF DEATH
531 frydery
....... IrInteiros
'FULL NAME Charles &
Fogles
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
53 Judon avenue
Winthrop Mass
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
191
.......
(Month)
(Day)
' DATE OF BIRTH
February.
(Month)
(Day)
(Year)
· AGE
72
10
.mos. .....
14
ds.
or ......
.min. ?
· OCCUPATION
Konstant House
(a) Trade, profession, or
particular kind of work ..........
apreciar
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Brooklyn,
new york.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
new York
12 MAIDEN NAME
OF MOTHER
may Dliscon
13 BIRTHPLACE
OF MOTHER
(State or country)
New York.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
53 Tracyde
16
Filed
191
REGISTRAR
1844
17
I HEREBY CERTIFY that I attended deceased from
October 23019
....
....... and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows : Chrome endocardite initial
Faortic valves. General passie congestion- arteriosclerosis
(general)
.(Duration)
.
yrs.
.
Contributory.
(SECONDARY)
(Duration)
C
yTs.
mos.
ds
(Signed)
Rowan & Soul
M.D
Nov 15, 1916 PA
YAddress)
Winthrop, man
* 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 Hollywood Senastey Nov 15. 1918
20 UNDERTAKER Auch 9
ADDRESS
202 HampelnSo
Jejich & Williams Cambados man
(City or town.)
St. :... ..... ............... Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
3 SEX
4 COLOR OR RAÇE
male White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
1ª DATE OF DEATH
November
14
3
(Year)
to
Nov 14"
191
that I last saw heam alive on
Nov 14ª
191
L
1130%
mos.
ds.
arterio belereais
7
?
10 NAME OF
FATHER
John Feche
....
If LESS than
1 day. ....... hrs.
RECORD.
ANENI
PERMAN V.SI.SIT
1966 -
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 occupation 3 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 minc, 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 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 faet 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," 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," "Uracmia," "Weakness," etc., when a definite discase 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.
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
catherine Hamn
1ª BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
C. R. Person
(Address)
14) Wollteh &h
16
Filed 191
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
(Year)
que
1916
, to
An 17
1916
... .
that I last saw hun alive on
Hus 1'2'
,
1916
and that death occurred, on the date stated above, a
850%
m.
The CAUSE OF DEATH* was as follows :
China Intestating Leshits
(Duration)
yrs.
.......
.. mos.
ds.
Contributory (SECONDARY)
(Duration).
yrs.
........
mos.
ds.
(Signed)
Ihr 19
191 6 (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
.. y.rs.
.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
1916
20 UNDERTAKER
ADDRESS
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
* FULL NAME
Catherine Procon
with of Pane. F. Brown
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 26/ Thuley tte Within Registered No. ......
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Female
4 COLOR OR RACE
Mite
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
" DATE OF BIRTH
× (Month)
(Day)
7 AGE
If LESS than I day ......... hrs.
or ...... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
housewife
(b) General nature of industry,
business, or establishment In
which employed (or employer).
9 BIRTHPLACE
(State or country)
England
10 NAME OF
FATHER
Richard Jennings
11 BIRTHPLACE
OF FATHER
(State or country)
known
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No.
26/Shirley
St. :
Ward)
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
100
(Month)
17
1916
(Day)
(Year)
1
58
... yrs.
M.D.
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, 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) Groccry; (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- kcepcrs who reccive 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- 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 fcver (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid usc 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, 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 scpticaemia," "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, ctc.
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.
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)
Boston Mass
12 MAIDEN NAME
OF MOTHER
Adeline Richards
13 BIRTHPLACE
OF MOTHER
(State or country)
Preten Mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Strait Gomb
(Address)
19 Freemont of Winething
16
Filed 191
REGISTRAR
Winthrop
BOSTON
.......
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Charles F lass
* FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband,I
@RESIDENCE
19 Arehereut It With ch
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Singli
(Year)
" AGE
If LESS than
! day ......... hrs.
57 yre.
3
mos.
9
ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work.
Celek
(b) General nature of Industry.
business, or establishment
which employed (or employer)
Railway Gelenk
P. O.
9 BIRTHPLACE
(State or country)
Boston
Contributory
(SLCONDARY)
(Signed)
.. mos. ............
ds.
(Duration)
( 2)mutual
M.D.
191 ....... (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 Mt Culum Cemetery
DATE OF BURIAL
Nov. 20
1916
2
20 UNDERTAKER
ADDRESS
Charleston
18ª
(Day)
.... .
1916
(Year)
17
I HEREBY CERTIFY that I attended deceased from
to
Nov 18
6
out
1916.
.............
....
191.
..
that I last saw him alive on
An 18"
, 1916,
and that death occurred, on the date stated above,
at ),50 Am.
......
The CAUSE OF DEATH* was as follows :
mitral regurgitation
bajo condition
Did a surgical operation precede death ?
Date
(Duration)
3
mos ..
dı.
10 NAME OF
FATHER
Thomas Cass
16 DATE OF DEATH
(Month)
· DATE OF BIRTH
9º 1859,
(Month)
(Day)
[10-'16-XXM.]
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop ........... (NO ......... 19 Areemout
St. :
............. Ward)
... yrs.
CHAHas38 NISHVW
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 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 inany cases, especially in industrial employments, it is nceessary 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," cte., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid House- keepers wlio 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 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 fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oceu- pation whatever, write Nonc.
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