USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 46
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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 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; Broneho- 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, ctc. The contributory (second- ary or intercurrent) affection need 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," "Collapsc," "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 Aiseases resulting from childbirth or miscarriage, as "PUER- PERAL septieacmia,", "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, Homieide, 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.
R. 15-8-'15. 100,000.
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
(No. 5 3 Cottage Pt. Pd. St.
...... „Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
William augustus Monroe
[If married or divorced woman or widow give maiden name, also name of husband.] 5 3 Cottage OG. Qd.
@RESIDENCE
53 Cottage Ak Rid
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX In.
4 COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
.........
(Month)
(Day)
(Year)
· DATE OF BIRTH
Feb.
(Month)
(Bay) 9 1841 (Year)
7 AGE
If LESS than [ day ......... hrs.
75 yrs. 11 mos . 22 ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Cabinet maker
(b) General nature of industry, business, or establishment In which employed (or employer) ..
17
I HEREBY CERTIFY that I attended deceased from
Cruq
1916
., to
Jany 31, 1917
that I last saw hun alive on
Jaby 31, 1917
and that death occurred, on the date stated above, at 5 00
m.
The CAUSE OF DEATH* was as follows : acute Cardiac Dilection
Indiai deutch,
Conetrituelary arterial Sclerosis
Diabil Milletina. 4 years
Contributory ..
duration.
(SECONDARY)
gangrene
.(Duration).
„yrs.
mos. ..............
ds.
(Signed)
Quelle E Salveson
M.D.
Sorry 31, 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, OR RECENT RESIDENTS).
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
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mr. Verney
(Address)
53 Cottage the. Hd.
16
Filed
191
REGISTRAR
19 PLACE OF BURIAL OR RECOVERY
Mass
DATE OF BURIAL Heb. 3. 1917
Forrest Hello
ADDRESS 2.326#
20 UNDERTAKER
gs Malerman for Washington et
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Mindenown mark
12 MAIDEN NAME
OF MOTHER
Katherine maynard
Carrie, Unknow
In the
13 BIRTHPLACE
OF MOTHER
(State or country)
suplicary
10 NAME OF
FATHER
William monroe
9 BIRTHPLACE
(State or country)
Princeton, Mass,
16 DATE OF DEATH
tomy
31. 1917
........
C
.---
1 7
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, 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 terni 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, 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- 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 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 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
12 MAIDEN NAME
OF MOTHER
Stannah A. Wilson
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Nature floyd
(Address)
36 Center St.
16
Filed.
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
w
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Undound
" DATE OF BIRTH
4 (Month)
9
861
(Day)
... , (Year)
7 AGE
If LESS than
I day ......... hrs.
55 yrs. 9 mos. 24 da.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Pariter
(b) General nature of Industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Nathrop
(Duration)
.. yrs. .........
mos.
1
ds.
Contributory
Jobar Pneumonia
(SECONDARY)
.(Duration)
yrs.
.........
mos. ............
ds.
(Signed)
Charles 7. mahoney
M.D.
....
..........
1919 (Address)
356 unschwer
* 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 Nultrap Cent.
DATE OF BURIAL
5
..
ADDRESS
20 UNDERTAKER
H.C. Ska 990
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
William- 9. Floyd
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
aRESIDENCE 36 Centeret. Winthrop.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
2
(Month)
(Day)
2
1917
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Jan.
30
191.2,
1917.
that I last saw hid alive on
feb 2
191 ... 7 ,
and that death occurred, on the date stated above, at
11. 45 Pm.
The CAUSE OF DEATH* was as follows :
qualmia
10 NAME OF
FATHER
Der B. Delayed
11 BIRTHPLACE
OF FATHER
(State or country)
Winthrop
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthropp
(No. 6)
36
Center
.St. ;..
.Ward)
-
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to eaclı 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) Groecry; (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, ete. 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, 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, 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 faet may be indicated thus: Farmer (rctircd, 6 yrs.). For persons who have no oceu- 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 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, peritoneum, etc., Carcinoma, Sar- coma, ete., of. ..... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles; Whooping cough; Chronic valvular heart disease; Chronie interstitial nephritis, etc. 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- aemia" (merely symptomatic), "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 aseertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ete. 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop (No.22 Irwin St St. ;......... Ward) .......
.............................
2 FULL NAME
GPANVILLE OLIVER AVEPY
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
28 TRUTH ST.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
6 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) WIDOWED
MALE
WHITE
* DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day ......... hrs.
66
yrs. mos. .ds.
or ....... min. ?
* OCCUPATION
PETIFED
(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)
MIDDLEBOPO MASS.
10 NAME OF
FATHER
Unknown
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Unknown
12 MAIDEN NAME
OF MOTHER
Unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
Unknown
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
C. O' Callahan
(Informant)
(Address)
22Pennsylvania Ave SOMINDULILY
16
Filed
191
REGISTRAR
...
0
(Month)
(Day)
1917. (Year)
17 I HEREBY CERTIFY that I attended deceased from
,1917
7f 4ª
191
2
to
that I last saw h alive on 191.2. and that death occurred, on the date stated above, at 1010Am. The CAUSE OF DEATH* was as follows : Labas Pneumonia
.(Duration)
............. yrs. ................ mos. 3 ds.
Contributory
(SECONDARY)
(Signed)
.......
.(Duration)
631 melcall
...... .... M.D.
765
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, OR RECENT RESIDENTS).
In the
At place
of death
... yrs.
............
.......
.. mos.
ds.
State ............
... уга.
mos.
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
HOLYHOOD CEM. BROOKLINE
DATE OF BURIAL
FEB. 6 1817 191
20 UNDERTAKER
John J. O. maley
ADDRESS
TINTIIPOP
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.
(City or town.)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
....
16 DATE OF DEATH
Feb
4'
-
1
....
.. yrs. .............
.mos.
...........
ds.
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, c. g., Farmer or Planter, Physician, Compositor, Architcet, 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.
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 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 iin- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mcre 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 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. Deathis supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized discasc, 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Wanttwoh ..... (No .... ..... ........ 19,
..... Coral Cuz.
St. :.................... ... Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Herbert G. Gaddis
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.].
@RESIDENCE
19 Coral aos. Trittund
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
(Month)
E
(Day)
,
191.7
....
(Year)
17
I HEREBY CERTIFY that I attended deceased from
762
1912.
to
76.4
1917
....
76.4ª
1912
......
that I last saw him
alive on
.... and that death occurred, on the date stated above, at 9.40 P.m.
The CAUSE OF DEATH* was as follows :
Hemophilia (congenital)
Hemorrhage for storech Bres
(Duration)
............. yrs.
...........
... mos.
4
ds.
Contributory (SECONDARY)
(Duration)
........... yrs.
............. mos.
.........
ds.
(Signed)
76 62
1917 (Address).
worthop
.........
* 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
...... y.s.
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
arlington muss.
...
191.7
20 UNDERTAKER
ADDRESS
Day Judge Low Carbunge
16 Filed , 191
......
REGISTRAR
16 DATE OF DEATH
Single
1894
(Year)?
If LESS than
[ day ......... hrs.
or ........ min. ?
9 BIRTHPLACE
(State or country)
Combinado amass,
3 SEX
Un.
' COLOR OR RACE
ws.
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
May
(Month)
(Day)
7 AGE
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Clark
(b) General nature of Industry,
business, or establishment
which employed (or employer).
10 NAME OF
FATHER
Dand Gad dis
11 BIRTHPLACE
OF FATHER
(State or country)
Suland
12 MAIDEN NAME
OF MOTHER
Sarah Dix on
PARENTS
18 BIRTHPLACE
Ireland
OF MOTHER
(State or country)
important. See instructions on back of certificate.
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
....
RG yra
9
mos.
Xds.
14 THE ABOVE IS TRUE TO THE REST OF MY KNOWLEDGE
David Gaddis
(Informant)
(Address) 19 Carol Que Centrale
....... M.D.
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 oceupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, Loeo- motive engineer, Civil engineer, Stationary fireman, cte. But in many eases, 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 specifieation, as Day laborer, Farm laborer, Laborer - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid House- keepers who reecive 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 oceupations 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 faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oecu- pation whatever, write None.
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