USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 39
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culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, ete., of. .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); Mcasles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intereurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "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 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 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, cte.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Tinthrop ....... (No. 95 Somerset Ave.
St. :. ................ Ward)
(City or town.)
[If deeth occurred in a hospitel or institution, give its NAME insteed of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
& SINGLE,
MARRIED,
WIDOWED,
Single
(Write the word)
$ DATE OF BIRTH
Dec
AIR
(Month)
(Day)
... (Year)
7 AGE
If LESS then
i day ......... hrs.
..... yrs. mos. ds.
or ... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or esteblishment In which employed (or employer)
(Duration)
.. yrs.
...........
mos.
ds.
Contributory
(SECONDARY)
(Signed)
(Duration)
R.B. Ganhar
........... yEs.
................ mos. ...............
.ds.
M.D.
De 1, 1911
(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 plece
of death.
.. yrs.
.. mos.
ds.
Stete ............ yrs. ........... mos.
............ ds .___.......
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
St. Michael:
Poxbury
DATE OF BURIAL
Dec 2JOIE
191
30 UNDERTAKER
ADDRESS
Filed
191
......
REGISTRAR
16 DATE OF DEATH
Drc
(Month)
(Day) 1
191 (Year)
17 I HEREBY CERTIFY that I attended deceased from
1
19!
6
to
1916
nevis
that I Tast saw h EN alive on 1 .... 1916. and that death occurred, on the date stated above, at ........... ..... m. The CAUSE OF DEATH* was as follows :
Stillfor
9 BIRTHPLACE
(State or country)
Winthrop
10 NAME OF
FATHER
Frank Tenking
11 BIRTHPLACE OF FATHER (State or country) New York
PARENTS
12 MAIDEN NAME
OF MOTHER
Louisa Smith
1ª BIRTHPLACE
OF MOTHER
(State or country) Eoston
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Frank Jenkins
(Address)
05 Somerset Ave.
16
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
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
important. See Instructions on back of certificate.
......
......... .
ichr & albaley
2 FULL NAME Stillborn Jenkins .......... [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 95 Somerset Ave,
-
Dec. 11916
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, 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 nccded. 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 morc 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. - Namc, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same. discasc. Examples: Cerebro-spinal fever (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," unqualificd, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, ctc., of .... ........ .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart 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" (mercly symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," ctc., 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. Statc 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 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, ctc.
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
Lura Gumingham
13 BIRTHPLACE
OF MOTHER
(State or country)
Freedom Maine
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address)
minttual maso
15
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
Female Marile
5 SINGLE,
married
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
December
(Day)
2º 194
(Year)
$ DATE OF BIRTH
June
(Month)
13 di
1866
17
I HEREBY CERTIFY that I attended deceased from
laly 1st
(Day)
(Year)
to
, 1916
Dec. 29 196.
? AGE
If LESS than
[ day ......... hrs.)
19 ds.
...
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
House wife
(b) General nature of industry,
business, or establishment in
which employed (or employer)
Surcowa of neck
(Duration)
3
.... yrs.
.........
.mos. ............... .ds.
Contributory
Hugeanlage
(SECONDARY)
(Duration)
.. yrs.
mos. 16
ds.
(Signed)
Willian & Partir
-
M.D.
1916
(Address)
Winthrop
* 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
Marton Gemeten De c 4
6
191
.......
20 UNDERTAKER
H. S. Hatch
ADDRESS
Brookline
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Minttuofmass (NO. 78 Cottage are
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Fred P. Hinter
78 battage que Winthrop- Mars
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
BOSTON (City or town.) .
Mellie Frances Sisters maiden st Haney
....
(Month)
that I last saw her
alive on
1916
and that death occurred, on the date stated above, at
1-05 m.
1
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
Bufal Maint
16 NAME OF
FATHER
Charles st. Haney
11 BIRTHPLACE
OF FATHER
(State or country)
maine
.yrs.
5
mos.
Luec: 2, 1716
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion 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 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 "Laborcr," " 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 occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE 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 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- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," " 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 provisions of chapter 24 of the Revised Laws deaths under the following 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.
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. 165
Kurs Road S
St. :
..........
Ward)
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Lucile Victoria Kugess
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
165 Rover Road Voiture
Registered No.
MEDICAL CERTIFICATE OF DEATH
{ COLOR OR RACE
Vinte
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Lingue .
16 DATE OF DEATH
December 5 1916
...
(Month)
(Day)
(Year)
· DATE OF BIRTH
1878 17
(Month)
(Day)
..
(Year)
7 AGE
38
yrs.
mos.
.ds.
or ....
min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Buyer
(b) General nature of industry,
business, or establishment In
which employed (or employer)
9 BIRTHPLACE
(State or country)
Boston Mass.
PARENTS
12 MAIDEN NAME
OF MOTHER
Adelia Cornell
13 BIRTHPLACE
OF MOTHER
(State or country)
Karton Warz.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Charles R Bennison
(Address)
16
Filed 191
REGISTRAR
(Duration)
2
yrs.
„.mos. ................ ds.
Contributory ...
Uremia
(SECONDARY)
Pohat Barney
.. (Duration)
... yrs. ...........
.mos.
ds.
......
M.D.
(Signed)
1916 (Address) Ihrenestou Sh
.........
* 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 Winthrop Limiting
DATE OF BURIAL
alle 7
1916
DO UNDERTAKER
ADDRESS
Charles R. Bennison Winthrop
...
to
191
5
6
that I last saw her alive on
16!
·
.......
1.20 am.
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows :
Quonie parenchymatous nephritis
10 NAME OF
FATHER
James de Rique.
11 BIRTHPLACE OF FATHER (State or country) Boston Muss.
If LESS than
| day ......... hrs.
I HEREBY CERTIFY that I attended deceased from nov 14
.......
$ SEX
Female
PERSONAL AND STATISTICAL PARTICULARS
Avec . 5, 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, 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 needcd. 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," ctc., 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- kecpers 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- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same diseasc. 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, ete., Carcinoma, Sar- coma, etc., of .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; 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 (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 ascertaincd as the cause. Always qualify all discascs resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State eausc 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, ctc.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1916.
CITY OF BOSTON.
FULL NAME
CHARLES LEMONT
Registered No. 11912
Place of Death }
Boston
and Residence S
Date of Death
DEC.9
1916. Age 41
years 4
months 25 days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
MAR.
Maiden Name
Husband's Name
Birthplace
LITCHFIELD.ME.
Name of Father
JOHN W.LEMONT
Birthplace of Father
LITCHFIELD.ME.
Maiden Name of Mother
ALICE ODIORNE
Birthplace of Mother
RICHMOND.ME.
Occupation TELEPHONE ENGINEER
Informant
Place of Burial or removal
LITCHFIELD.ME.
Undertaker W.C.SKAGGS
WINTHROP
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 :
EG
RAR'S
R
BICUT (Duration)
OFFICE
CTYYTA
BOSTONIA CONDITAA
BO SHEGIMI
HE DONATA A.
OSTON. MASS
Contributory · (Duration)
(Signed) S.A.CLEMENT M.D.
DEC.9 1916
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT.I DAY
Usual Residence
WINTHROP ( 107 COURT RD)
Filed
DEC. 15
1916.
A true copy.
Attest :
Eumylenen
Registrar.
MALIGNANT SCARLET FEVER
CITY
MASS . HOMEO . HOSPT .
LUC 4, 1916
.
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
Chelsea, Mass.
(No.
Frost do spt.
St. :
............ Ward)
CHELSEA (Clty or town.)
[If death occurred in a hospital or institution, give its NAME instead of streat and numbar.]
* FULL NAME
Plakias
(S.B. )
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
21 Nevada St. , Winthrop, Lass.
Registered No. 787
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
White
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Dec. 12. 1916.
(Month)
(Day)
191
(Years
· DATE OF BIRTH
Dec. 11 - 1916.
(Month)
(Day)
(Year)
If LESS than
1 day ........ hrs.
--- .................... yrs. --- mos. -- - ds.
or ........ min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work.
----
........
Asphyxia Neonatorum
(Duration) - yrs.
mos.
- ds.
Contributory Hace presentation-version (SECONDARY)
(Duration) yrs. .. mos. dı.
....... .............
(Signed)
Dolbort L. Jackson
M.D.
Dec. 12
1916
(Address)
362 Comm'th Ave.
* 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
.... mos. .........
Where was disease contracted, if not at place of death ?.
Former or
usual residence.
Bos ton, Mess.
19 PLACE OF BURIAL OR REMOVAL Gardon Cem.
DATE OF BURIAL
191
........
20 UNDERTAKER
C. H.
Feunce
ADDRESS
Chelsea
* SEX ilo le 7 AGE PARENTS WHITE PLAINLT, WITH ONFADING INK - THIS IS A PERMANENT RECORD. (b) General nature of Industry. business, or establishment which employed (or employer)
10 NAME OF FATHER George
11 BIRTHPLACE
OF FATHER
(State or country)
Greece
12 MAIDEN NAME
OF MOTHER
Georgia Carofield
18 BIRTHPLACE
OF MOTHER
(State or country)
Greece
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Frost Hospt.
(Address)
Chelsea
15 Filed ..... Doc. 14, 191 ... 6.
....... .............. .......
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased trom
Dec.11
191
6 to
Dec. 12, 191 6
........
that I last saw h ....... i.Malive on
1.2 ..... 191 .... 6,
and that death occurred, on the date stated above, at ..... 2-4QA
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
Chelsea, Mass.
.............
1
.
aHos RF
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative licaltlifulness of various pursuits can be known. The question applies to caclı 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 wlien needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Groecry; (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. Wonen 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
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