USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 5
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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, ete.
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-1916.
CITY OF BOSTON.
FULL NAME
CYNTHIA MAGEE
Registered No.
1388
Place of Death { and Residence
Boston
Date of Death
JAN.31
MASS.CHAR.E.& E. INF.
1916. Age 65
years 5
months 14
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
MAR
Maiden Name
WHITNEY
Husband's Name
WINTHROP MAGEE
Birthplace
WESTMINSTER
Name of Father
HORACE WHITNEY
Birthplace of Father
WESTMINSTER
Maiden Name of Mother
MARY SAWIN
Birthplace of Mother WESTMINSTER
Occupation
AT HOME
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from 1916, to
1916, 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 : S
R AR'S
PATRIBUS SIT DE Primary ( Duraløn
CITY
OFFICE
DOUBLE AC . SUPP. MASTOIDITIS 6 WEEKS ( OPR. JAN . 3 & 28. 1916)
STO
Contributory . (Duration) LOBAR PNEUMONIA - 2 DAYS
(Signed)
C.E. WELLS M. D.
JAN. 31916 SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
WINTHROP(WINTHROP CEM)
WINTHROP
Usual Residence
W. C. SKAGGS
FEB. 4
Undertaker
Filed
1916.
WINTHROP
A true copy. Attest : Enmblement
Registrar.
CTYTTATIS
BOSTONIA
CONDITAA.
16 31. REGIMIME DONATA A. N. MASS
ATA A. 1822.
ANI DNIOVINA
3
TI IHM
Jan. 31, 1916
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.
16
Filed 191
..........
REGISTRAR
16 DATE OF DEATH
(Month)
22, 1916
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
1916
, to
76-2
1956
that I last saw him alive on
1916
and that death occurred, on the date stated above, at.
) p.m.
The CAUSE OF DEATH* was as follows :
Hypertrophy of Thymus Bland
(Duration)
.. yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration)
yrs.
mos.
1
US.
(Signed)
+6 3º
1916
(Address)
winthing
* 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 New Calvary
DATE OF BURIAL
Feb 3, 1916
20 UNDERTAKER
ADDRESS
15 Chambers Ir
3 SEX
6 DATE OF BIRTH
7 AGE
& OCCUPATION
(a) Trade, profession, or
particular kind of work
' BIRTHPLACE
(State or country)
10 NAME OF
FATHER
PARENTS
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
(b) General nature of industry,
business, or establishment in
which employed (or employer)
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
8
,
(Year)
If LESS than
! day ......... hrs.
yrs.
1
mos.
ds.
Or ....... min. ?
11 BIRTHPLACE OF FATHER (State or country) Boston
12 MAIDEN NAME
OF MOTHER
Mary C. Boylan
13 BIRTHPLACE
OF MOTHER
(State or country)
Boston
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
J. L. Ruske
(Address)
75 Chambers hr
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH Winthrop ManNo. 131 /highland les.
Joseph F. Rogers for
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
131 Highland are
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
(Month) (Day)
(City or town.)
M.D.
1
€
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion 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 occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE 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 ro- 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 disease can be ascertained as the cause. Always qualify ali 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 provisions of chapter 24 of the Revised Laws deaths under the following 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
|12-'15-XXM.]
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH Winthrop
1 PLACE OF DEATH Winthrop
(No. 52 Wave Way Ave .. St. : ......... Ward)
BOSTON (City or town.) [If death occurred in a hospital or institution, givo its NAME instead of street and number.]
2 FULL NAME
Alice J.Briggs.
[If married or divorced woman or widow give maiden name, also name of husband.] Alice J. Greyson wife , of Tyler L. Briggs. @RESIDENCE 52 Wave Way Ave. Winthrop. Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
COLOR OR RACE
white
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCEDmarried.
(Write the word)
16 DATE OF DEATH
Feb 4 1916
(Month)
(Day)
191
(Year)
· DATE OF BIRTH
Sept 15 1866
1
(Month)
(Day)
(Year)
7 AGE
49
4
... yrs.
mos.
20
ds.
or ......... min. ?
8 OCCUPATION
(a) Trede, profession, or
particular kind of work
Housewife.
(b) General nature of industry, business, or establishment in which employed (or employer).
Did a surgical operation precede death ? no, Date
(Duration)
.... yrs.
mos. . ...
ds.
Contributory ..
(SECONDARY)
(Duration) .. yrs. ......... .mos.
/
ds.
(Signed)
Ach, 5
..... 191 ......
(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.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Tyler L. Briggs.
(Address)
S3 Have Way Que.
16
Filed
191
....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
..
...
17
I HEREBY CERTIFY that I attended deceased from
Ich, 2d
to
......... .
6
Hel. 5.
1916.
that I last saw hele alive on
Hel. 4th
1916
......
and that death occurred, on the date stated above, at
5
m.
The CAUSE OF DEATH* was as follows :
Lafar Pracumoura
9 BIRTHPLACE
(State or country)
Port Richmond N. Y.
10 NAME OF
FATHER
Joseph Greyson
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
England.
12 MAIDEN NAME
OF MOTHER
unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
unknown
19 PLACE OF BURIAL OR REMOVAL Mass. Crematory.
DATE OF BURIAL
1xB. b
1915
20 UNDERTAKER
Swaterman dans.
ADDRESS
Baston
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
If LESS than
I day ......... hrs.
....
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 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 minc, 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," "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 scpticaemia," "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.
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
11 BIRTHPLACE
OF FATHER
(State or country)
Preston Eng
12 MAIDEN NAME
OF MOTHER
armie Miller
13 BIRTHPLACE
OF MOTHER
(State or country)
Preston, Eng.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
a. a. Delson
(Address)
44 Trident arc.
16
Filed 191
REGISTRAR
no.450.
BOSTON (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
*FULL NAME
Margaret a. Nelson
Margaret Pigg (France ). nelson
[If married or divorced woman or widew.
give maiden name, also name of husband.]
@RESIDENCE
1 Short St. East Boston
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
* SEX
4 COLOR OR RACE
20
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manied
18 DATE OF DEATH
February
4. 1916
....
(Month)
(Day)
(Year)
· DATE OF BIRTH
May
Tionth)
(Day)
(Year)
' AGE
73
8
mos.
.....
16 da.
ds .
or ........ min. ?
· OCCUPATION
(a) Trade, profession, or
particular kind of work
Housewife
(b) General nature of industry,
business, or establishment in
which employed (or employer).
Home
Did a surgical operation precede death? ho Date .
(Duration)
6
.yrs.
......... mos.
ds.
..............
Contributory
(SECONDARY)
..... Duration)
.............. yrs.
mos. ...........
ds.
(Signed)
M.D.
Feb 4, 1916 (Address)
728 SaratogaSt
* 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
.ds.
State ............ yrs. .........
mos.
ds .............
of death ............ yrs.
mos.
Where was disease contracted, If not at place of death ? Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Holy Cross
DATE OF BURIAL
Feb 7.
1916
......
20 UNDERTAKER
/ 200 ftAines
ADDRESS 699 Paratzasta E. Boston
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
Winthrop
(No.
44 Videnfare.
Ward)
.....
that I last saw ben ...... a live on.
Fil 4
196
and that death occurred, on the date stated above, at
5 Am.
The CAUSE OF DEATH* was as follows. bitrate
of heart
9 BIRTHPLACE
(State or country)
Preston. Eng.
10 NAME OF
FATHER
John Pigg
If LESS than
I day ......... hrs.
.... ... y ... .............. . ...
19
1842
17
I HEREBY CERTIFY that I attended deceased from
august 1, 1916, to.
Fl. 4
1911
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- kecpers 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 homc. 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 re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber .
culosis of lungs, meninges, peritoneum, 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 septicacmia," "PUERPERAL peritonitis," etc. State eausc 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.
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
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 321
...
.St. ..
...... ..................... Ward)
(City or lown.) [If death occurred In a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
Gladys M. Aleckman
[If married or divorced woman of widow give maiden name, also name of husband.] @RESIDEN 052/ Pleasant It, Harthiofs,
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Fe
4 COLOR OR RACE
w
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Jungle
· DATE OF BIRTH
8 23
(Month)
(Day)
. 1903
(Year)
7 AGE
If LESS than [ day ......... hrs.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work .........
(b) General nature of industry, business, or establishment which employed (or employer).
9 BIRTHPLACE
(State or country)
Dayton Ohis
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Dayton Beher
12 MAIDEN NAME
OF MOTHER
Clara Niveau
18 BIRTHPLACE
OF MOTHER
(State or country)
Dayton.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Watter Leckman.
(Address) 321 Pleasant St
15
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
2
(Month)
(Day)
1916
(Year)
191
17
6
I HEREBY CERTIFY that I attended deceased from
July
1915
to
that I last saw he alive on
Fely
3
6
191
..........
and that death occurred, on the date stated above, at
245am.
The CAUSE OF DEATH* was as follows :
Ulcerative Endocarditis
(Duration)
×
.yrs. ....
>
X ds.
mos. .....
.....
Contributory
(SECONDARY)
.(Duration)
yrs.
mos. ds.
......
(Signed)
Quiere & Salesare M.D.
Fully 5, 191.
......
( 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. ...........................
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Dayton Ohix
DATE OF BURIAL
2-8
191
6
20 UNDERTAKER
ADDRESS
....
..........
..............
12 yrs.
5 mos.
12 ds.
10 NAME OF
FATHER
Watter Heckman
-
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
Registered No.
SIHL - XNI DNIOVINO HIIM XINIVT4 2:IM
Feb . 4, 1916 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, Architeet, 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," "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 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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