USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 42
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Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cercbro-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., Careinoma, Sar- coma, etc., of ... ................. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie valvular heart disease; Chronie 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," "Scnile," 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 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 eliapter 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 deathis of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
& SEX MALE · DATE OF BIRTH 7 AGE & OCCUPATION (a) Trade, profession, or particular kind of work (b) General nature of industry. business, or establishment which employed (or employer). 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (State or country) 12 MAIDEN NAME OF MOTHER PARENTS important. See Instructions on back of certificate. (Address) 16 Filed 191 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 .... ......... .. yrs.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
INTHPOP
.........
(No. 7 ATLANTIC ST.
St. ;..
.......................
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
? FULL NAME
STILLROPN
STRA
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE 7
ATLANTIC ST.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
11
191_
7
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
191.
..... , to
11
., 191-2.
.... ......
that I last saw hun alive on
191
........ .
and that death occurred, on the date stated above, at
............ m.
The CAUSE OF DEATH* was as follows :
Stilllow
(Duration) ................ yrs. ............... mos. .......... .ds.
Contributory
Premature
(SECONDARY)
(Duration)
yrs.
........... mos. .............
ds.
(Signed)
17 mahoney
M.D.
I2012. 1917 (Adres).
350 Umibaby
........
* 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.
In the
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
1/13 17.
191
IT. MICHAELS CON. DAY 20 UNDERTAKER
ADDRESS
TOUN F. O' MALEY
WINTHPOF
.. .
JAN
TI
(Month)
(Day)
IAI7 (Year)
If LESS than
[ day ......... hrs.
mos. ds.
or ....... .. min. ?
9 BIRTHPLACE
(State or country)
FINTHPOP MASS.
ILLEGITIMATE
UNKNOWN
HAZEL SHEA
18 BIRTHPLACE
OF MOTHER
(State or country) TINCHENDON MASS
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
MPS. J. J. MONAHAN
7 ATLANTIC ST.
REGISTRAR
4 COLOR OR RACE
WHITE
$ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
SINGLE
PERMANENT RECORD.
11,1917
STANDARD CERTIFICATE OF DEATH.
1
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," "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. 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 oecu- 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 fever (the only definite synonyın 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); 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: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "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 septicemia," "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, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, 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)
WOPCESTEP MASS.
12 MAIDEN NAME
OF MOTHER
MABEL CUPRIE
18 BIRTHPLACE
OF MOTHER
(State or country)
CANADA
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
John H. Mcauliffe
(Address)
TO" PUTNAM ST.
16 Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
$ DATE OF BIRTH
Oct.
16
(Month)
(Day)
1218
(Year)
7 AGE
If LESS than
1 day ......... hrs.
... yrs. 2 mos. 2f ds. or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry. business, or establishment in which employed (or employer) ..
..........
.(Duration) .
5
............... yrs. .............
... mos.
ds.
Contributory.
(SECONDARY)
ds.
(Signed)
Raymond Btacker
M.D.
191 ...... / (Address).
Winthing ! Me.
...........
* 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
.mos.
......
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
191
BOIL CROSS MALDEN
I/13/17:
ADDRESS
20 UNDERTAKER Tohn F. O' Maley
Winthrop
·
............
(No. 107 PUTNAM ST.
.....
.St. . Ward)
(City or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME FRANCIS POREPT MCAULIFFE [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE I07 PUTNAM
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
Jan
(Month)
12
(Day)
1917
(Year)
17 I HEREBY CERTIFY that I attended deceased from
11
1911, to
12
1917,
that I last saw hw alive on
Pan
2
. 1917. and that death occurred, on the date stated above, at 6 A .m. The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
"INTHPOP MASS.
10 NAME OF
FATHER
JOHN H. MCAULIFFE
Male
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
WINTHPOP
At place
of death ............ yrs.
... mos. .......
ds.
State ...
.......... yrs.
.........
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) 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 fcver (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuher-
ENHAVJNA HUM
culosis of lungs, meninges, peritonaeum, etc., 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: 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 ascertaincd 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 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 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.
The Commmuwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop. ...... 328 Pleasan X St. : .Ward)
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
? FULL NAME
Henry.
Christian Peterson
[If married or divorced woman or widow
give maiden name, also name of husband.] ..
@RESIDENCE
325 Pleasant St.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
While.
1 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
· DATE OF BIRTH
Lept.
(Month)
(Day)
7 AGE
If LESS than
( day ......... hrs.
59
.yrs.
mos.
22
ds.
.....
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Boston Celot.
(b) General nature of Industry, business, or establishment In which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Dinmärk.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Denmark.
12 MAIDEN NAME
OF MOTHER
Elizabeth Moller
1ª BIRTHPLACE
OF MOTHER
(State or countryQ
Denmark
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Wir H.C. Peterson
(Address)
3.28 Phusand Lt
16
Filed 191
...... REGISTRAR
16 DATE OF DEATH
...
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
that I last saw h Im alive on
12
, 191)
and that death occurred, on the date stated above, at/0 Am.
The CAUSE OF DEATH* was as follows :
Carcinoma of Posterior mediostrial
glands
(Duration)
1 yrs.
......... ds.
Contributory
(SECONDARY)
.. (Duration) ..
... yrs.
mos. ds,
31 Metcal
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 ............ 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 Woodlawn Limiting Jan, 14/ 1917
20 UNDERTAKER ADDRESS Chan. R. Banion Winthrop
12 1917
22
18557
(Year)
December
1916 ..
Jan. 12"
1917.
10 NAME OF
FATHER
Held. Peterson
(Signed)
13
1917
(Address)
Withro
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, 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 linc 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, 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 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 discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cercbro-spinal meningitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (nevcr 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 nced not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "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 septieaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. 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 onc 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-1917.
CITY OF BOSTON
FULL NAME
OLGA F. BYRAM
Registered No. 413
Place of Death ¿ and Residence 3
Date of Death
917,
Age 72
years 2
months 20 days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
WIDOWED
Maiden Name
SIEDLER
Husband's Name
EDWARD K. BYRAM
R
AR TRIBIs Primary ty (DurationO
ROBIS
Birthplace
GERMANY
Name of Father
EDWARD SIEDLER
Birthplace of Father
NEW YORK N. Y.
Maiden Name of Mother
ELIZABETH UNGER
Birthplace of Mother GERMANY
Occupation
JAN 12
1917
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
WINTHROP
Usual Residence WINTHROP
Filed
A true copy. Attest :
JAN 17 1917.
1
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from 1917, to 1917, 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 :
APOPLEXY (3DAYS )
CITY
BOSTONIA
VTT
CONDITAA
16 30.
8
MINE DONATA A ON. MASS.
ST
-
Contributory : (Duration)
OLD AGE
(Signed)
D.A.ELDREDGE
M.D.
Informant
R
AOFFICE
A. 1822.
Undertaker
C.F. BROWN BOSTON
Registrar.
Boston BURNAP HOME JAN [2
C
خسرـ
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.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
"Cohasset Mass.
12 MAIDEN NAME
OF MOTHER
Jula a. Stall
13 BIRTHPLACE
OF MOTHER
(State or country)
Boston Was
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Chas & Care
(Address)
322
Pleasant.
15
Filed 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Manual
· DATE OF BIRTH
(Month)
3
1878
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
1916
.,
, to
1917
...
If LESS than
[ day ......... hrs.
that I last saw him
... alive on
Yan
14
191.2
and that death occurred, on the date stated above, at
11.15h The CAUSE OF DEATH* was as follows : Carcinoma / Brain Carcinoma M Brast
.(Duration)
... yrs.
6
mos.
ds.
Contributory.
(SECONDARY)
.(Duration)
.. yrs.
mos.
.............. ds.
(Signed)
31 Metcall.
M.D.
1917 (Address).
* If death followed injury or violence the certificate of death must be made ont 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 Mt Centrum Cremetore Jan 17, 1917
20 UNDERTAKER Char R. Bunun Winthrop
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Helen Hall Case-
[If married or divorced woman or widow give maiden name, also name of hnshand.] @RESIDENCE 322 Pleasant of
Helen Hall. Jowan- Chan. A. Care
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
Jan. 14
191.Z
..
(Month)
(Day)
(Year)
7 AGE
28 .... yrs. 2 mos.
ds.
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)
Boston Wars.
10 NAME OF
FATHER
Abraham Tower
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No. 322.
Pleasant
St. : ............ ... Ward)
IN3D
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," "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 Nonc.
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