USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 40
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. 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- BASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the samo discase. 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"); Lobur pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber
culosis of lungs, meninges, peritonacum, cte., Carcinoma, Sar- coma, etc., of. „(nanie 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" (mercly 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 tlie 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, E.c- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
1
R 18. 3-'16. 10,000.
1
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.
[10-'16-XXM.]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No ........ 480 Winthrop
'FULL NAME Mary Jackson
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 480 Winthrop St.
PERSONAL AND STATISTICAL PARTICULARS
1 SEX
4 COLOP OR RACE
Fremale White
5 SINGLE,
MARRIED
WIDO WED,
OR DWORCED
(Write the word)
Married
' DATE OF BIRTH
(Month)
(Day)
(Year)
' AGE
58
...... yrs.
mos.
ds
or ....... min ?
& OCCUPATION
(a) Trede, profession, or
particular kind of work
House Wife
(b) General nature of industry. business, or establishment which employed (or employer).
9 BIRTHPLACE
(State or country)
Russia
10 NAME OF
FATHER
Daniel Saperstein
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Precia
12 MAIDEN NAME OF MOTHER gittel Unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
Buscia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Samuel Labaon
(Address)
He Trident Que.
15 Filed : 191
REGISTRAR
1ª DATE OF DEATH
Decour
20th
(Month)
(Day)
( Year)
17
I HEREBY CERTIFY that I attended deceased from
1910
to
1916
If LESS than
day,
.. hrs.
that I last saw h /4 alive on
gegent 4th
1916
and that death occurred, on the date stated above, at.
.... m
The CAUSE OF DEATH* was as follows :
chyv-and Endocarding
Did a surgical operation precede death ?
Date
(Duration)
............... yrs.
.............
.mos. ds.
Contributory. (SECONDARY)
(Duration)
yrs.
ds
(Signed)
....
M.D
See. 21 1916 (Address) 193 Hunterallan
* 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.
mos.
ds ..
.ds.
State
..... yrs.
......
Where was disease contracted,
if not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL Keine Woburn agudatte
DATE OF BURIAL
Dep. 20191.
6
20 UNDERTAKER Seeob Stanete
ADDRESS
Basta
BOSTON
(City or town.) [If deeth occurred ir e hospita' or institution, give its NAME instead of street and number.]
........ Ward)
Mary Saperstein wife of abraham,
Registered No.
MEDICAL CERTIFICATE OF DEATH
191.6 ....
aHOO3d LNaNYWE
Ve
20 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 occupation 3 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 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 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, 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, ctc. 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- acmia" (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 street, or one supposed to be due to Alcoholism, etc.
17-
- 4. Deaths under circumstances unknown, as A person found dead, etc.
aquanti
active
1-
5
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)
New York City N. C.
12 MAIDEN NAME
OF MOTHER
Cellen J. Smith
13 BIRTHPLACE
OF MOTHER
(State or country)
Boston Mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Cornelius M. Doherty
(Addr
36 Pearl ave Withlow
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Arc 21
(Month)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
1916
to
191
6
.......
6
that I last saw h.f .....
alive on
Utc 16
191
... ........ , and that death occurred, on the date stated above, at 7A. m.
The CAUSE OF DEATH* was as follows : Chimie Bronchitis- Mancandilis
(Cauces of Larmix "obentión 14 years ago).
Did a surgical operation precede death ?
Date
(Duration)
10
.yrs.
.............. mos. ................ ds.
Contributory.
acute imuchuté
(SECONDARY)
(Duration)
.. yrs.
mos.
........
(Signed)
....
DECLI
..........
1916
(Address)
416 warcho fr
* 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 ..
......
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 Atoly Cross
DATE OF BURIAL
Dec 23, 1916
20 UNDERTAKER
R. J. Buke
...... .. Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
* FULL NAME
Cella Same Doherty
[If married or divorced woman or widow
11
give maiden name, also name of husband.]
@RESIDENCE
36 Pearl ave Wintherof Mass.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female White
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,-
OR DIVORCED
(Write the word)
Married
$ DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
46 yrs.
„mos. ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Atous
scwife
(b) General nature of Industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
Boston Mass.
10 NAME OF
FATHER
Philip Daly
Minttuof Mass BOSTON
|12-15-XXMI.] The Commonwealin of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Minttuof Mass
.... (No .....
36 Pearl Che
St. ;
Daly- Cornelius M. Doherty
16 Filed 191
ADDRESS
lehi culestown
6
.ds.
....
M.D.
191 (Day) 6
If LESS than
day ......... hrs.
gyo93y __ LNINYWUdd
Dec . 21/ 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 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) 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, ctc. 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 fact may be indicated thus: Farmer (rctired, 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 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 use of "Tumor" for malignant ncoplasms); 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage,". "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease ean be ascertained as the 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 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, etc.
. 4. Deaths under circumstances unknown, as A person found dead, ctc.
.
R. 15-8-'15. 100,000.
MIOYANA.ALIM WINIY IA
SI __ STHX
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
Blanche the Broadfirst
1ª BIRTHPLACE
OF MOTHER
(State or country)
Habefar n. 8-
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informan
Willard 2 Store
(Address) 19 cherry Sti Winthrop
m
16
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month) 23 196 .........
(Day)
(Year)
$ DATE OF BIRTH
7
4
(Month)
(Day)
7 AGE
If LESS than I day ......... hrs.
Or ........ min. ?
& OCCUPATION
(a) Trede, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
1916 17 I HEREBY CERTIFY that I attended deceased from July 4 1916, to (Year) the 230 1916 .... . that I last saw him alive on 220 1916 and that death occurred, on the date stated above, at. 730 Am. The CAUSE OF DEATH* was as follows : Amplimenu
(Duration)
.. yrs. ..............
mos. ....
3
de.
Contributory
(SECONDARY)
(Signed)
(Duration)
631 Mulcul
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. ............
ds.
State
........ yrs.
mos.
ds .............
In the
Where was disease contracted, if not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Dear Island Ceed 12-24. 1916
20 UNDERTAKER W.C. Skaggs
ADDRESS
..........
(City or town.)
1 PLACE OF DEATH
(No.
19
cherry
St. ;................. .Ward)
" FULL NAME
Dorothy B. Stone
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Winthrop- 19 chimp St.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
4 COLOR OR RACE
w
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
...
......
9 BIRTHPLACE
(State or country)
Wirchrap
10 NAME OF
FATHER
Wieland& Store-
11 BIRTHPLACE OF FATHER (State or country) ") Sheridan, Mo.
mos. ..........
ds.
191 ..
(Address)
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
"yrs.
5 mos.
19
ds.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oeeu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to eachi 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 engincer, Civil engineer, Stationary fircman, 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," 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. Carc 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- 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," 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 im- portant. Example: Mcasles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mcrely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," cte.), "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 septicaemia," "PUERPERAL peritonitis," cte. 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, Suicidc, 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)
P
Treland
12 MAIDEN NAME
OF MOTHER
Catherine Burke
1ª BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
John T. Gibbons
(Informant).
(Address).
200 Main St. Milford
16
Filed
19t
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
$ SEX
Male
4 COLOR OR RACE
White
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED Married
(Write the word)
* DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
I day ......... hrs.
.min.
& OCCUPATION
(a) Trade, profession, or
Contractor
particular kind of work
(b) Generel nature of industry,
business, or establishment
In
which employed (or employer).
17
I HEREBY CERTIFY that I attended deceased from
Dec 17
19115, to
Der 24
1916
that I last saw h we alive on
Dec 24"
196
and that death occurred, on the date stated above, at.
1 0 m.
The CAUSE OF
DEATH* was as follows :
Pneumonia (exciting cause )
Cirrhosis of luvia
Pneumonia
(Duration) ......
............... yrs.
4
mos.
ds.
Contributory.
Cervera e Acasa congusto
(SECONDARY)
4 2 tesco & clevering
.(Duration)
mos. .....
2
.yrs. .......
ds.
(Signed)
Horace
avec 25
, 19111 (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).
In the
At place
of death
yrs.
mos.
ds.
State ............ yra. ............ mos.
......
ds ............
Where was disease contracted, if not at place of death ?. Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
St. Marys Milford
DATE OF BURIAL
Dec. 27
191
--
20 UNDERTAKER John F. O' Maley John
ADDRESS
inthr
(City or town.) [If death occurred in · hospital or institution, give its NAME instead of street and number.]
'FULL NAME
Bernard Gibbons
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
44 Bucannan &f.
....
Registered No.
16 DATE OF DEATH
December
(Month)
2.50
(Day)
.... 196
(Year)
PERSONAL AND STATISTICAL PARTICULARS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Tinthrop (No. 44 Fucannon St
......
St. ;.................... Ward)
.. yrs. mos. .ds.
9 BIRTHPLACE
(State or country)
Milford Mass.
10 NAME OF
FATHER
Hugh Gibbons
"CHOOJU INE
25/1916
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 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," "Dcaler," etc., without more precise specification, as Day laborer, Farm laborcr, Laborer - Coal mine, etc. Women at home, who 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 employcd, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.
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