USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 52
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14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16
Filed 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the woril)
Singer
6 DATE OF BIRTH
(Monthi)
(Day)
7 AGE
If LESS than I day, ........ hrs.
5
yrs.
mos.
14
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) ..
General Electric G
.(Duration)
.yrs.
....... mos. ds.
Contributory
(SECONDARY)
.(Duration)
mos.
.ds.
M.D.
.
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
.yrs.
mos.
ds.
State.
.. 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
Balletra Spar
11.4.
DATE OF BURIAL
D21/10.
191
ADDRESS
20 UNDERTAKER
DEQuite
8716
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
e the Beach) Ward)
2 FULL NAME
Claren
D. Malvon
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 48 0,
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
10 DATE OF DEATH march 29 191 (Yer)
(Month)
(Day)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
arthur 10 Malroy
11 BIRTHPLACE OF FATHER (State or country)
·
........
(City or town
[If death occurred in a hospital or institution, give its NAME instead of street and number.}
12
18.97
(Year)
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 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 necded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Forcman, (b) Automobilc 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 laborcr, Farm laborcr, 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, 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 Scrvant, 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 "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, peritonacum, cte., 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 symptomatie), "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 septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoncd by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."
Cases for the Medical Examiners. - Under tlie 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 strect, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 16.8.'13. 5,000.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1917.
CITY OF BOSTON
FULL NAME
CHARLES WEST
Registered No.
3580
Place of Death {
Boston
CARNEY HOSPT.
and Residence S
Date of Death
MAR.29
1917,
Age 72
years
months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
W
Maiden Name
Husband's Name
AORTIC REGURGITATION
Birthplace
ENGLAND
Name of Father
THOMAS WEST
its0.
Birthplace of Father
ENGLAND
Contributory : (Duration)
--
Maiden Name of Mother
RACHEL THORNTON
Birthplace of Mother
ENGLAND
Occupation
LABORER
Informant
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
Undertaker
EVERETT (GLENWOOD)
A.T .DOUGLASS
Usual Residence WINTHROP( 187 BOWDOIN ST)
Filed
MAR . 31 1917.
A true copy. Attest :
CHELSEA
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 :
TR
AR Primary
TRIBUS
PAZ
CITY
HOBIS S
SOFFICE
CHR. INTERSTITIAL NEPHRITIS
BOSTONIA
CONDITAA.
$ 1822
STON
REGIMINE DONATH MASS.
(Signed)
D. J. HERLIHY
M.D.
MAR.29 1917
Registrar.
P
-
Much 29, 1917
IS A PERMANENT RECORD
SIHL
WHITE PLAINLY, WITH UNFADING INK
2
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
Sarah alynn
13 BIRTHPLACE OF MOTHER (State or country)
Novia Scotia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant
Edward Mc Clean
55 Warren 80 Lawn Masst. Mary's Cent.
15
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Pale White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH
Unknown
(Montlı)
(Day)
7 AGE
If LESS than I day, ........ hrs.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Shoemaker
(b) General nature of industry, business, or establishment in which employed (or employer)
(Duration)
............. yrs. ................ mos. ..
..........
.ds.
Contributory. (SECONDARY)
(Duration) ....... yrs. .. ds.
.........
.mos.
A
M.D.
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
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
despren Mass Sans 8, 199
20 UNDERTAKER f. H. Corcor Leyun Mask.
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME milleam.
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE VS warren So., lynn
2516
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
10 DATE OF DEATH
Mark 29.
(Month)
(Day)
191 7
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
my accidental
9 BIRTHPLACE
(State or country)
Novia Scotia
10 NAME OF
FATHER
Edward MGlearn
11 BIRTHPLACE OF FATHER (State or country) Novia Scotia
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
8804
{Signed)< may 70
1
(Year)
22 .. yrs. mos. ds.
STH HNI DNIOVANO HIIM ATNIVTỪ 91.IHM
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 caclı 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," "Forcman," "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 (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 discasc. 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, 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, 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 septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deathis 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 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. 16-8.'15. 5,000.
important. See instructions on back of certificate. 15 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 PARENTS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
IPLACE OF DEATH
(N
St. ...
Ward)
[If death occurred in a hospital or institution. give its NAME instead of street and number.]
2517
Registered Nox
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male White
6 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the word)
single
6 DATE OF BIRTH
Unknown
(Monthı)
(Day)
1
(Year)
7 AGE
If LESS than I day, ....... hrs.
mos.
ds.
Or ........ min. ?
B OCCUPATION Machinest Helper
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
Gen. Electric lo.
9 BIRTHPLACE
(State or country)
Lynn Plass.
10 NAME OF
FATHER
Sames Gaffney
11 BIRTHPLACE OF FATHER (State or country) dreland
12 MAIDEN NAME OF MOTHER Bridget Mc Jurgin
13 BIRTHPLACE OF MOTHER (State or country)
chreland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
James Gaffney
(Add ) 6 Essex St. Sorun Mas
Filed 191
REGISTRAR
16 DATE OF DEATH
March 29, 1917
(Day)
(Jord May
(Month)
(Yepr)
I HEREBY CERTIFY that I have investigated the 17
death of the deceased.
The CAUSE OF DEATH* was as follows :
Drow
accidental.
(Duration)
.......
... yrs. ................ mos. .............
ds.
Contributory (SECONDARY)
(Duration)
.. yrs.
mos. ds.
(Signe
M.D.
...... , 19
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
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 St. Josephis bent. doyun Mask
DATE OF BURIAL Mays.
20 UNDERTAKER ADDRESS J. H. Corcoran Login Mass.
8803
(City or town.)
(Sound Withup Bank )
2 FULL NAMEC
flerey-
[If married or divorced woman or widow give maiden name, also name of usband.] @RESIDENCE 6 Extent
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
.yrs. 3
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 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, 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) Groccry; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Forcman," "Manager," "Dealer," etc., 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, 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, 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, peritonacum, etc., Carcinoma, Sar- coma, ete., of. ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles; Whooping cough; Chronic valvular hcart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease eausing 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," "Uracmia," "Weakness," ete., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL scpticacmia," "PUERPERAL peritonitis," ete. State cause for which surgical operation was undertaken. For VIOLENT DEATHIS State MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, OF HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under tlie head of "Contributory."
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- 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 dcad, etc.
R. 16-8.'15. 5,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
.. (No .. Boston Harbor St. ;.. Ward)
.Boston (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME FRANCIS GIRARD, [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 8 Fosdick Terrace Ivry, Masc.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
White
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single.
6 DATE OF BIRTH
June 1 (Month) (Day)
1899 (Year)'
7 AGE
If LESS than
I day, ........ hrs.
.yrs. 10 mos. -
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Shoemaker
(b) General nature of industry, business, or establishment in which employed (or employer)
(Duration)
.yrs.
mos. ds.
9 BIRTHPLACE
(State or country)
Exeter, N.H ..
Contributory (SECONDARY)
(Duration) ... yrs.
mos.
ds.
(Signed)
,
M.D.
Apr. 7, @17 (Address)
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
.. yrs.
mos.
ds.
State
.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
St. Mary's Com. Lynn.
Mass ..
DATE OF BURIAL
apr. 8. 1917.
(Address)
8 Fosdick Terrace, Lynn.
1 5
Filed
., 191
REGISTRAR
20 UNDERTAKER
M. P. Haven
ADDRESS
Lynn, Mass ..
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
10 NAME OF
FATHER
James Girard
11 BIRTHPLACE OF FATHER (State or country)
Canada,
12 MAIDEN NAME
OF MOTHER
Elizabeth Watson
13 BIRTHPLACE OF MOTHER (State or country)
Scotland.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. James Girard (Mother
16 DATE OF DEATH March 29 - 30 ., 191.5
(Month) (Day) (Year)
17 1 HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : Drowning, accidental ( shipwreck. )
met. 24 -5 0
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can bo known. The question applies to each and every person, irrespective of age. For many occupations a single word or torm 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 Hlouscwife, 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 Scrvant, 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 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 re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
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