USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 45
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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 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-
n
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: Mcaslcs (disease eausing 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 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 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, 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.
170Grover Ave.
St .:
.
Ward)
.........
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
THOMAS
HENRY CONNOR
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
IZOGPOVER AVE.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
' COLOR OR RACE
MALE
WHITE
· DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
If LESS than I day ......... hrs.
45
.yrs. mos. ds.
or ....... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
HATTER
(b) General nature of industry,
business, or establishment In
which employed (or employer).
9 BIRTHPLACE
(State or country)
DANBURY CONN.
PARENTS
12 MAIDEN NAME
OF MOTHER
UNKNOWN
18 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)Mrs. Mary E. Foris
(Address)
TTO GROVER AVE.
16
Filed
191
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
191.7 ... , to
....
20
form 24-
191 ......
that I last saw h
Im alive on
Ham
230
....
191.2
and that death occurred, on the date stated above, at
12 3/4 m.
The CAUSE OF DEATH* was as follows :
Labas Pneumonia
Left uffun lobe
(Duration)
............ yrs. ................ mos.
6
ds.
Contributory
(SECONDARY)
(Duration)
.... yış.
mos.
ds.
.........
(Signed)
M.D.
Hm 25, 1997 (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).
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
ST .PETERS DANBURY CONN.
DATE OF BURIAL
1/26/17
191
20 UNDERTAKER TOHN F. O'MALEY
ADDRESS WINTHROP
16 DATE OF DEATH
Jan
24
(Month)
(Day)
191
7
(Year)
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) SINGLE
MEDICAL CERTIFICATE OF DEATH
10 NAME OF
FATHER
UNKNOWN
11 BIRTHPLACE
OF FATHER
(State or country)
IFELAND
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 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 (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 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: 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," "Collapsc," "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 septicacmia," "PUERPERAL peritonitis," etc. State cause for whichi 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, 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
[10-'16-XXM.]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop ... (No. Metralf Hospitales: Ward)
Winthrop BOSTON -
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
*FULL NAME
Baby Macho
[If marricd or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
12 Sea Foam Live,
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1 SEX
Male
4 COLOR OR RACE.
White
5 SINGLE.
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Dunque
" DATE OF BIRTH
day.
15
(Mouth)
(Day)
(Year)
, AGE
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).
9 BIRTHPLACE
(State or country)
Winthrop, Mass,
10 NAME OF
FATHER
Monis Jacko
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Ruadia
12 MAIDEN NAME OF MOTHER Lena Schneider
1ª BIRTHPLACE
OF MOTHER
(State or country)
Russia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
father
(Address)
12 Jea Fram Quy.
Filed 191
REGISTRAR
1919
17
I HEREBY CERTIFY that I attended deceased from
Jun 15
191_2_, to.
tom 25
1912
........
that I last saw him alive on
Jan 24
5 and that death occurred, on the date stated above, at 345 Am The CAUSE OF DEATH* was as follows : manilion premating toby
light 4 lbs)
Did a surgical operation precede death ?
Date
.(Duration)
.......
yrs. ..............
mos. 10
ds.
Contributory ( SECONDARY)
(Duration)
.... yss.
......
. mos. ds
(Signed)
M.D
Am25, 1917 (Address)
VIf 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 deatn.
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 Cut DATE OF BURIAL Wolver, Beth Joseph Day 26 91 7
20 UNDERTAKER DDRESS Jacob Stanetsky Boxton
(Mouth)
25
(Day)
1917
(Year)
18 DATE OF DEATH
Jam
yrs. mos. 10 ds.
important. See instructions on back of certificate.
-
SVIND-HLIM AINEVIA AUUML
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) Forcman, (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, 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. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber
culosis of lungs, meninges, 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 discase; 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure,". "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from elrildbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Belmont
.. (No .... Benjamin Road. Ward)
John &, Bell
?FULL NAME
[If married of divorced woman or widow
give maiden name also name of husband.]
@RESIDENCE
Winthrop mass
Registered No.
8
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1 SEX
+ COLOR OR RACE
20
i SINGLE
MARRIED,
WIDOWED
PH DIVORCES
Hvit the word)
Widower
1ª DATE OF DEATH
January 26
197
(Year)
(Montlı)
(Day)
· DATE OF BIRTH
May 23
(Month)
(Day)
1844 17
(Year)
I HEREBY CERTIFY that I attended deceased from
Jan 24, 197
to
Jan 26
1917.
that I last saw halive on. Samme 25, 197
and that death occurred, on the date stated above, at.
1,90
The CAUSE OF DEATH* Was
6
as follows :
Labas Pneumonia
(b) General nature of industry,
business, or establishment in
which employed (or employer)
Mason
· BIRTHPLACE
(State or country)
Carleton P.E.a.
10 NAME OF
FATHER
John Bell
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Country Carlisle, Eng,
12 MAIDEN NAME OF MOTHER Damit Campbell
13 BIRTHPLACE
OF MOTHER
(State or country)
barliste, Eng,
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Samuel. Bell
(Address)
Belmont
Filed ....
REGISTRAR
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 Wünschen, Jazz, 197
20 UNDERTAKER
Edwin L Derby
ADDRESS Cambridge
.............
mos.
6
ds.
Contributory. (SECONDARY)
ds.
(Signed)
.(Duration) David L Martin .... yrs. ... mos.
M.Q Sam26, 1917 (Adr
X Rosedale Sh Dorch
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
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.
Belmont
City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
, AGE
22
8
yrt.
mos.
3
ds.
Or ........ min. ?
If LESS than
i day, ....... hrs.
* OCCUPATION
(a) Trade, profession, or
particular kind of work
Contractor
(Duration)
.........
.yrs.
Jan. 26, 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 cach. and every person, irrespective of age. For many occupation 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) Forcman, (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 DEATHE (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 "('roup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- precumonia ("Pneumonia," unqualified, is indefinite); Tube.
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: 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," "Uracmia," "Weakness," etc., when a definite disease can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or iniscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ctc. 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 21 person found dcad, etc.
1: 18. 3'16. 10,000.
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.
[12-'15-XXM.|
The Commmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Veintrop
(No ...
74
Reed
St. ......... Ward)
..... (City or town.) [If death occurred in a hospital or institution, gide its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
+ COLOR OR RACE
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
18 DATE OF DEATH
Jan
380
, 1917
...
((Month)
(Day)
(Year)
· DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
... 80
.yrs.
.mos.
ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
......
at Horne
(b) General nature of industry,
business, or establishment
which employed (or employer).
Did a surgical operation precede death ?
no
Date
.(Duration)
.... yrs.
moş. ................
ds.
Contributory
Chronic Amchilic
(SECONDARY)
(Duration)
....... yrs.
mos. ................ ds.
(Signed)
.....
n.a morison
M.D.
Sam 30
, 1917
(Address).
80 Princeter DI.
............
(* 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.
DATE OF BURIAL
1917
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
......
17
I HEREBY CERTIFY that I attended deceased from
at intervals for ipeperal years
191
.....
that I last saw hy alive on
....
Jan 21
1917
......
and that death occurred, on the date stated above, at.
3 a. m.
The CAUSE OF DEATH* was as follows :
mitral hourgitt
asthma,
.............
9 BIRTHPLACE
(State or country)
Leland.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Leland.
12 MAIDEN NAME
OF MOTHER
Unkown.
1ª BIRTHPLACE
OF MOTHER
(State or country)
cheias
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Daughter
(Address)
54 Creed St Vunnithet
16
19 PLACE OF, BURIAL OR REMOVAL Holy Cross
20 UNDERTAKER Il Kinky
ADDRESS
East Bustin
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
BOSTON
Hannah. Simpson
"FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 74. Read. St. Virtual- Mars
Hannah Muller Edward Sind un
Registered No.
widow
If LESS than
I day ......... hrs.
10 NAME OF
FATHER
Thomas Muller
STANDARD CERTIFICATE OF DEATH. /
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loeo- 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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