USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 47
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Statement of cause of death. - Name, first, the DIS- CASE CAUSING DEATH (the primary affeetion with respect to time and eausation), using always the same aceepted term for the same discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic eerebro-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, ete., Carcinoma, Sar- coma, ete., of .... ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (seeond- ary or intereurrent) affection need not be stated unless im- portant. Example: Measles (discase eausing 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," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage,", "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., when a definite disease ean be ascertained as the cause. Always qualify all Aiseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," cte. State eause for which surgical operation was undertaken.
4
.
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 violenee, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
2. Deaths supposedly eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ete.
4. Deaths under circumstances unknown, as A person found dead, ete.
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.
PARENTS
12 MAIDEN NAME
OF MOTHER
Franco Maneira
Mamuna
18 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
16
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
5ª
191>
....
(Month)
(Day)
(Tear)
· DATE OF BIRTH
(Month)
(Day)
(Year)
? AGE
If LESS than 1 day ........ hrs.
.. yrs. ........ 2 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)
(Duration) ...
mos.
2
ds.
Contributory
(SECONDARY)
.(Duration) Augustus & Vacuum .. yrs. M.D.
(Signed)
191. 2 ... (Address)
........... Effestore
* 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
losa Mardin
......
191M
20 UNDERTAKER
timetomally
(City or town.)
I PLACE OF DEATH
(No ........
Metcalf Avefila
.......
St. :
...... Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Many Chichdeacor
' FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
19 Thermoche Sta02.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Achat
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
....
3 1. 1919 17 I HEREBY CERTIFY that I attended deceased from
, 1912 ... , to
1917
that I last saw hit alive on 765 1917 .... , and that death occurred, on the date stated above, at ...... .m. The CAUSE OF DEATH* was as follows :
-
.
mos.
.
ds.
10 NAME OF
FATHER
You& Click Eacom
11 BIRTHPLACE OF FATHER (State or country) radom.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
..............
ADDRESS
STANDARD CERTIFICATE OF DEATH. 5,1917
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, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, ete. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) 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, ete. Women at home, who are engaged in the dutics of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged ill domestic service for wages, as Servant, Cook, Housemaid, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (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 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, ete. 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- acınia" (merely symptomatie), "Atrophy," "Collapse," "Comna," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., when a definite disease ean be ascertaincd 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 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 PLACE OF DEATH 3 SEX Iunie · DATE OF BIRTH 7 AGE & OCCUPATION (a) Trade, profession, or particular kind of work 9 BIRTHPLACE (State or country) PARENTS 13 BIRTHPLACE OF MOTHER (State or country) (Informant) important. See instructions on back of certificate. 15 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 11
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
22
1/16
(Month)
(Day)
..
(Year)
If LESS than I day ......... hrs.
... yrs.
mos.
10
ds
or ..
min. ?
(b) General nature of industry, business, or establishment which employed (or employer)
4
10 NAME OF
FATHER
Kalund Ha Billent Thetter
11 BIRTHPLACE OF FATHER (State or country) )
12 MAIDEN NAME
OF MOTHER
LA Luce
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)
14Publie Une Penere
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
set
1917
.....
(Month)
(Day)
(Year)
17
1 HEREBY CERTIFY that I attended deceased from
,1917
to ..
191
that I last saw belle
r
alive on
Hex. 7.
., 191.2
and that death occurred, on the date stated above, at.
The CAUSE OF DEATH* was as follows :
..... m.
aceito nephritis-
(Duration)
6
.yrs. ................ mos. ds.
Contributory
(SECONDARY)
.(Duration) .yrs.
mos. 10 ds.
H.C. Porto
M.D.
(Signed) Hep, St., 1917
Muchas
* 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.
In the
ds.
State ............ yrs. ............ mncs. ............ ds ........
Where was disease contracted, If not at place of death ?.
Former cr usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
, ProulTiva 2
10
1917
20 UNDERTAKER
ADDRESS Beve hun is
.......
Tire.
.....
1
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
14 1 cobble
1
1
1
St. :
Ward)
(No
...... ....
, 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) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," cte., 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 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); 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- aemia" (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 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1917.
CITY OF BOSTON
FULL NAME OCTAVIUS MASON
Registered No.
1706
Place of Death ¿ and Residence S
Boston
FEB. 9
1917,
Åge
84
years
months 28
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
W
Maiden Name
Husband's Name
ONTRIBUS Pri Ory
SE(Duration
NOBIS
OFFICE
Name of Father
THOMAS MASON
Birthplace of Father ENGLAND
Maiden Name of Mother
Birthplace of Mother
ENGLAND
W. A .MORRISON
M.D.
Occupation
ENGINEER (RETIRED)
FEB . 9 1917
SPECIAL INFORMATION from Hospitais, Institutions, Transients, or Recent Residents.
Place of Burial or removal
EVERETT (WOODLAWN)
Usual Residence
WINTHROP (42 BEAL ST)
Filed
FEB. 13 1917.
Undertaker
E.G.BROWN & SON
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 :
CEREBRAL EMBOLISM
Birthplace
ENGLAND
CITY
CTVTTAT
BOSTONIA
CONDITAA.
8
IC30.
EGIMINE DONATA
ST
TASS
S
ON. Contributory : (Duration )
ARTERIO-SCLEROSIS
(Signed)
Informant
RA
.0. 1822
A true copy. Attest : ENMSlenen
Registrar.
12 BENNINGTON ST.
Date of Death
ERMANENT RECURTY.
71917
7
110-'16-XXM.|
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No ...
31
Thornton
St. ;.... Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Joseph Almeida Flores
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
31 Thornton St.
.... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
· DATE OF BIRTH
Oct
(Month)
(Day)
187%
(Year)
If LESS than
[ day ......... hrs.
(a) Trade, profession, or
particular kind of work
Salesman
Goal
9 BIRTHPLACE
(State or country)
Provincetoure, Mass
10 NAME OF
FATHER
Joseph Flores
unknown
Unknown
mintención
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mro Edith &. Flores.
(Address)
31 Thornton St.
15 Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
February
9
(Month)
(Day)
1917
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Ojaly 4
1917
to
1917
that I last saw hacer alive on
Fily 9
197
and that death occurred, on the date stated above, at.
83º am
The CAUSE OF DEATH* was as follows :
Double Labar Pneumonia
Did a surgical operation precede death? ho
Date
.(Duration)
X yrs.
X
mos.
ds.
Contributory.
(SECONDARY)
(Duration)
.........
.yrs.
mos. .. ds
(Signed)
Fely 9
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.
.......
In the
mos.
ds.
....
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Winthrop mass
DATE OF BURIAL
Feb. 11, 1917
20 UNDERTAKER
M. J. Jelly
ADDRESS
Il Meridian It.
E. Boston.
1 SEX
Male
" AGE
46
& OCCUPATION
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
PARENTS
13 BIRTHPLACE
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
(b) General nature of industry,
business, or establishment in
which employed (or employer) ....
&
yrs. .........
4
mos.
ds.
.............
2
„min. ?
BOSTON
M.D
state 110WG SNVIDIS DISAHd
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, Loco- motive engineer, Civil engineer, Stationary fireman, cte. 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 nceded. 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 hiome, 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 faet 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 fever (the only definite synonyın is "Epidemie 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, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ... ..... (name origin: "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, cte. 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," "Weakness," ete., when a definite disease ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. 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- posure, ete.
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.
|12-'15-XXM ]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
65 Revere
...... Y .....
A Gauchew- Ernest Beckie
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 65 Revise St.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
mand
· DATE OF BIRTH
Feb. 4 1856
(Month)
(Day)
(Year)
If LESS than
& day ........
........ hrs.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ...
Palesmia
4
man
(b) General nature of industry. business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Worcester Mars
10 NAME OF
FATHER
James Reckie
11 BIRTHPLACE
COF FATHER
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
Elizabeth Heller
13 BIRTHPLACE
OF MOTHER
(State or country)
Scotland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Filed
191
....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Feb. 15
191
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
12
1917, to
Mb 15
1912.
....
that I last saw hun alive on
726
15
1917
and that death occurred, on the date stated above, at Am.
The CAUSE OF DEATH* was as follows :
Cerebral hemorrhage
artimil Sclerosis
Did a surgical operation precede death ? ho
Date
(Duration)
......... yrs.
............
.mas.
.ds.
3
Contributory ..
(SECONDARY)
(Duration)
2 yrs ..
mos.
......... ds.
(Signed)
Raymond B Parken
M.D.
$.1917 (Address)
148 Winthrop ST
......
* 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 ............ yra.
.......... mos. .
Where was disease contracted, If not at place of death ?. Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Forestdale ConFeb. 17, 1917
20 UNDERTAKER
CaRollins
ADDRESS
ElBoston
2 FULL NAME 3 SEX 7 AGE PARENTS (Informant) 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 ...........
Winthrop
BOSTON
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. :...............
....... Ward)
Registered No.
1
61
yrs. mos. ........... .... ds.
or ......... min. ?
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 agc. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architcet, Loco- motive engincer, Civil engineer, Stationary fircman, 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," "Dcaler," 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 employcd, 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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