USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 43
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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 terin for the same disease. Examples: Cerebro-spinal fever (the only (lcfinite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid usc of "Croup"); Typhoid fever (never re- port "Typhoid pne ponia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, 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; 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 septicemia," "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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
WINTHROP
(No.
304 PLEASANT ST.
........ .......
.St. ;...
.Ward)
(City or town.) [If death occurred in e hospital or institution, give its NAME insteed of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Can
(Month)
.
(Day)
.F
1917
(Year)
· DATE OF BIRTH
JAN
I017
(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 establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
WINTHROP
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
MILFORD MASS.
12 MAIDEN NAME
OF MOTHER
MAPY P. NELSON
13 BIRTHPLACE OF MOTHER (State or country) HALTFAY N. S.
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Edward F. Adams
(Address)
304 Pleasant St.
Filed
, 191
...... REGISTRAR
...
17 I HEREBY CERTIFY that I attended deceased from
191.Z. t
1917
that I last saw h
alive ơn:
191
and that death occurred, on the date stated above, at.
............. m.
The CAUSE OF DEATH* was as follows :
Stilltom
.(Duration)
............... yrs. ................ mos. ...................
Contributory
(SECONDARY)
(Duration)
(Signed)
Clan15. 1917 (Address)
200 Atcasa 191
* 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.
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
TAN 19 1017
191
........
HOLY CROSS MALDEN
20 UNDERTAKER John F. O'Maley
ADDRESS
inthrop
3 SEX
MALE
1 COLOR OR RACE
WHITE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) SINGLE
STILLPOPN ADAMS
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE 304 PLEASANT ST.
....
10 NAME OF
FATHER
DWAPD E. ADAMS
M.D.
0 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 cngincer, 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 thereforc 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 (retircd, 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 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) ; Mcasles; 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Wcakness," 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 dcad, etc.
110-16-XXM.]
The Commomuralth of Massachusetts
STANDARD CERTIFICATE OF DEATH Wonthrop
1 PLACE OF DEATH Winthrop. (No. 36 Trident Ave. „.St. ;...... ..... „Ward)
BOSTON
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street und number.]
* FULL NAME Louisa N.Bishop.
[If married or divorced woman or widow Louisa N.Edwards widow of George .....
give maiden name, also name of husband.] @RESIDENCE 36 Trident Ave. Winthrop.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16.DAJE, OF DEATH Jan 18 1917 191
(Month) (Day) (Year.
$ DATE OF BIRTH
Feb 23 1842.
(Month)
(Day)
(Year)
TAGE
74
-75
10
mos.
26
ds.
.....
· 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)
Sydney C.B.
10 NAME OF
FATHER
John Edwards
1 BIRTHPLACE
OF FATHER
(State or count
ySydney C.B.
12 MAIDEN NAME
OF MOTHER
Louisa Duggan
18 BIRTHPLACE
OF MOTHER
(State or country)
England.
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. W. H.Rockwll.
Boston Mass
Filed 191
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
191,2,1
Jan. 12
191
If LESS than
1 day ........ hrs. that I last saw h & alive on
Man, 16
1917
......
and that death occurred, on the date stated above, at
The CAUSE OF .DEATH* was as follows:
Did a surgical operation precede death ?
W Date
.(Duration)
yrs.
.mos.
ds.
Contributory
(SECONDARY)
.(Duration)
... yrs.
mos. 20 da
(Signed)
M.D
cm. 19
1917(Address)C
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
... yrs.
In the
.........
.. mos.
ds.
State ............ yrs.
..........
... mos.
............ ds .............
Where was disease contracted, if not at place of death ?..
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Mt. Hope.
DATE OF BURIAL
Jan 21
191
...
" UNDERTAKER ES WatarmandSans
ADDRESS
$ SEX female PARENTS important. See instructions on back of certificate. (Address) 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 ........
' COLOR OR RACE
white
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCEDWidowed
(Write the word)
ł
or ........ min. ?
Y
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 eaelı and every person, irrespective of age. For many occupations a single word or term on the first line will bo sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fircman, etc. But in many cases, especially in industrial employments, it is 1 necessary to know (a) tho kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salcs- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," 4 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 Housc- keepers who receive a definite salary), may be entered as Housewife, Houscwork, 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, Houscmaid, 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 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: Cercbro-spinal fever (the only definite synonym is "Epidemie ecrebro-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 necd 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" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old agc," "Shock," "Uraemia," "Weakness," ete., 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 tho 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.
1
important. See instructions on back of certificate. N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should stato CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is vory
1 PLACE OF DEATH
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH
Township
Winthrop
State of ..
Massachusetts
Registered No.
Village
Post Hospital It Banks
St .;
Ward)
[If death occurred in a hospital or institution, glve Its NAME Instead of street and number.j
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
Married
6 DATE OF BIRTH
September
28
(Month)
(Day)
(Year)
7 AGE
26
. yrs
3
mos.
21
ds.
If LESS than 1 day, ____ hrs. or ____. min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)
The CAUSE OF DEATH? was as follows: hurpura hemorrhagica Septicemia (General Streptococcus) 4 ds. infection) cause unknown (Duration) - yrs. ________ mos.
Contributory. (SECONDARY)
(Duration)
mos,
ds.
(Signed)
Jan. 19
191-2
(Address)
Start Backs, Mais,
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS OF INJURY ; and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS)
At place
of death
yrs.
mos
ds. State
in the
yrs.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
( Informant )
31 Mutual)
(Address)
1St Le. MRC U.S. army
15
Filed 191
REGISTRAR
( Mond)
16 DATE OF DEATH
January
19 1917 (Day) (Year) attended deceased from
17
I HEREBY CERTIFY, That
January 15, 19:7
.
to
заплану 19, 191.7.
Jamary 19, 1917
That I last saw h.LWalive on.
and that death occurred, on the date stated above, at2. 40 1m.
9 BIRTHPLACE
(State or country)
Pennsylvania
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
ada Frieder
13 BIRTHPLACE
OF MOTHER
(State or country)
mcs.
ds.
Where was disease contracted,
if not at place of death ?
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE CF BURIAL
Manthrop Cemetery Jan 21
191.7
20 UNDERTAKER
ADDRESS Chance Beginn Writing
11 -- 3184
County
Suffolk
or
City
(No.
Frank F. Wells
2 FULL NAME
1890
.
-
J I. D.
[Approved by U. S. Census and American Public Health Association]
Statement of occupation .- Precise statement of occupation 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, Compos- itor, Architect, Locomotive 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial 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-Coul mine, etc. Women at home, who are engaged in the dutics of the household only (not paid Housekeepers who receive a definite salary ), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cool, 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUS- ING DEATII (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualificd, is indefi- nite); Tuberculosis of lungs, meninges, peritonaeum, etc., Car- cinoma, Sarcoma, etc., of . (name origin; “Can- cer" is less definite; avoid use of " Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The con- tributory (secondary or intercurrent) affection need not be stated unless important. Example : Measles (disease causing death), 29 de .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal condi- tions, such as "Asthenia," "Anaemia" (merely symptom-
atic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inani- tion," " Marasmus," "Old age," "Shock," "Uraemia,"' "Weakness," etc., when a definite disease can be ascer- tained as the cause. Always qualify all diseases result- ing from childbirth or miscarriage, as "PUERPERAL septi- chaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHIS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train-accident; Revolver wound of head- homicide ; Poisoned by carbolic acid-probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
NOTE .- Individual offices inuy add to abovo list of undesirable terms and refuse to accept certificates containing them. Thus tho form in use in New York City states: "Certificates will bo returned for additional information which givo any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, haemorrbago, gangreno, gastritis, erysipelas, meningitis, miscarriage, necrosis, peritonitis, phlebitis, pyaemia, septichaemia, tetanus." But general udoption of the minimum list suggested will work vast improvement, and its scope can be extended at a later date.
11-3184
Furfur
Septicemia Straft
0
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-X\M.]
The Commmmwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Winthrop
BOSTON
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
' FULL NAME Henry R. Thompson
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 36 Ingelside Ave.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1 SEX
male
4 COLOR OR RACE
white
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCEDmarried.
(Write the word)
18 DATE OF DEATH
Jan 19 1917
(Month)
(Day)
191
(Year
$ DATE OF BIRTH
June17 1870
(Month)-
(Day)
(Year)
' AGE
46
7
mos.
2
ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
none
(b) General nature of Industry, business, or establishment In which employed (or employer).
9 BIRTHPLACE
(State or country)
Brooklyn N.Y.
10 NAME OF
FATHER
Henry H. Thompson
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
unknown N. Y.
12 MAIDEN NAME
OF MOTHER
Caroline V. VanHousen
1ª BIRTHPLACE
OF MOTHER
(State or country)
unknown N. Y.
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
L. G. Thompson
(Address)
36 Ingelside Ave.
16
Filed 191
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
Jules
5
1916. to
Jan 19
1917
that I last saw hum alive on
19
1917
and that death occurred, on the date stated above, at 3 Am
The CAUSE OF DEATH* was as follows :
Lymples - Sarcoma
Inguinal and Illio-service aloud.
Did Osurgical operation precede death? yes, Date you 26
1916
(Duration) , y's. mos. ds.
Contributory.
(SECONDARY)
(Duration)
.yrs.
mos.
.............
da
{Signed)
R. B. Tanker
M.D.
Jan
19, 1917 (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, OS 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 New York N. Y.
DATE OF BURIAL
Jan 22, 1917
20 UNDERTAKER
ADDRESS
2326 Washington St
Boston Mass
1 PLACE OF DEATH
Winthrop.
(No 36 Ingelside Ave St. ;.. .Ward)
1
If LESS than
! day .........
...... hrs.
.... yrs.
Jan 19/1917
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 None.
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