USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 55
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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-
eulosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .... ...... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: 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.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
....
Lillian I Ley more
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 12 Bond St. Boston,
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
Feb-26
191_2 ... , to
april 16
1917
that I last saw h M alive on
apr 16
, 191 ......
and that death occurred, on the date stated above, at 6.25 /m.
The CAUSE OF DEATH* was as follows :
acute Endocarditis
Embolism, Hemiplegia
(Duration)
.yrs.
..........
.. mos.
48
.ds.
Contributory.
(SECONDARY)
(Duration) ..
... yrs.
mos.
ds.
(Signed)
31Metai
M.D.
afry 17, 197
(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
48 da.
In the 2
State.
ds ...
Where was disease contracted Bad St Sustin
If not at place of death ?..
usual residence ...
Former or
20 Bod ST Gration
(Informant)
grathe R. Sugneour
(Address)
12 Bond It Boxton
Filed 191
...
REGISTRAR
1894 17 (Year)
If LESS than ( day ......... hrs.
Or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
athome
9 BIRTHPLACE (State or country) Douglas-Isley man.
12 MAIDEN NAME OF MOTHER Hellen Frayer
1ª BIRTHPLACE OF MOTHER (State or country) Comwell Eng.
.
19 PLACE OF BURIAL OR REMOVAL Winthrop Cent
DATE OF BURIAL 4-18- 1917
20 UNDERTAKER I.e. Skaggs
ADDRESS
Winthrop.
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Priceson - halter R. Seymour
Registered No.
16, 197
....
(Month)
(Day)
(Year)
11
1 PLACE OF DEATH (No. 2 FULL NAME .. 3 SEX 4 COLOR OR RACE & SINGLE, MARRIED. WIDOWED. OR DIVORCED ( (Write the word) * DATE OF BIRTH 11 (Month) (Day) 7 AGE 22 ...... (b) General nature of industry, business, or establishment In which employed (or employer) 10 NAME OF FATHER Evan Budeson 11 BIRTHPLACE OF FATHER (State or country) PARENTS 14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE important. See Instructions on back of certificate. 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 ..... ..... ............... yrs. ......... 5 mos. J ds.
Ward)
............ yrs.
mos.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- pation is very important, so that tho relativo 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 linc 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," "Dcaler," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ctc. 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 in domestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of tlie 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, tho DIS- EASE CAUSING DEATH (the primary affection with respect to tine and causation), using always the same accepted term for the same diseasc. Examples: Cerebro-spinal fever (the only definito synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid usc 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; Chronie 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" (mercly symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ctc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Wcakness," 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 duc 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
11 BIRTHPLACE
OF FATHER
(State or country)
Russia
12 MAIDEN NAME
OF MOTHER
Sarah m. Unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
Russia
" THE ABOVE IS TRUE TO, THE BEST OF MY KNOWLEDGE
(Informant)
Husband
(Address)
41 Cutter It
16
Filed 191
....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
W.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
· DATE OF BIRTH
..
(Month)
(Day)
(Year)‘
7 AGE
If LESS than I day ........ hrs.
53 yrs. ....... mos. ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
House with
(b) General nature of Industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Russia
.(Duration)
.............. yrs. ................ mos.
1
.ds.
Contributory
(SECONDARY)
(Duration)
yrs.
.......
„mos. ..............
ds.
(Signed)
Edward) Franger.
.,
M.D.
apar .. 9
191 ..... , (Address)
49 Boulette Road
* 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. .........
de.
State
........... yrs.
............ mos ..
... ds ....
Where was dlsease contracted, if not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVIL Mayacak DATE OF BURIAL West Rax Pride of april 20191}
20 UNDERTAKER Jacob Stanethe
Winthrop
1 PLACE OF DEATH
STANDARD CERTIFICATE OF DEATH Winthrop ... (No. 41 Cutter
.St. ;... Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
? FULL NAME
Rase
alexander
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
41 butter It
case Cannold With Of Samuel
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
april
18 1912
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
apr. 17
1917.
apr. 18
...........
1917.
that I last saw her
alive on
apr. 18
, 1917, and that death occurred, on the date stated above, at .... .... m. The CAUSE OF DEATH* was as follows :
tente hammerricari Pancreatitis
......
...
10 NAME OF
FATHERA
Harris Can hold
1
ADDRESS
The Commonwealth of Massachusetts
A PERMANENT RECORD. SI SIHL=XNIENIAYANO HUMAINIVIA ALIUM
apr . 18/1917
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to cach and every person, irrespective of age. For many 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 houschold 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- CASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ...... .................. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mere)y 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 Aiseases 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. 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, ctc.
4
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. 19
Underhill
St. :
Ward)
.......
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
' FULL NAME
Henrietta P. Brown
......
[If married or divorced woman or widow
give maiden name, also name of busband.]
@RESIDENCE
19 Uncleprice St, Wintherfo
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
8 SEX
4 COLOR OR RACE
w
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
mar
" DATE OF BIRTH
3
(Month)
(Day)
27
1834
(Year)
7 AGE
If LESS than
I day ......... hrs ..
83
) yra.
mos. .... 21 ds.
„.min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
athome
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Bocalee. N.B.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Devonshire Eng.
12 MAIDEN NAME
OF MOTHER
Ella clark
13 BIRTHPLACE
OF MOTHER
(State or country)
Devonshire Eng.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Elija Brown
(Address)
19 underhice st
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
191.7 ... , to
Cpu. 18, 1917.
that I last saw her alive on
ak .. 18, 1917
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows :
.(Duration)
.......... yrs. ...........
.mos.
.
2
ds.
Contributory.
(SECONDARY) det
.(Duration)
yrs.
mos.
ds.
(Signed)
Cafer 14, 1917 (Address)
M.D.
* 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.
.. mos.
ds ..
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 BLACE OF BURIAL OR REMOVAL
Portland WE
20 UNDERTAKER
IL.S. Skaggs
DATE OF BURIAL
4-21.1917
ADDRESS
Filed 191
16 DATE OF DEATH
4 18, 1917
(Month)
(Day)
(Year)
10 NAME OF
FATHER
It~ Braddock
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 linc will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engincer, 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 laborcr, Farm laborcr, Laborer - Coal mine, cte. Women at home, who are engaged in the duties of the household only (not paid House- kcepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fcver (the only definito synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid usc 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 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" (mercly symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haeinorrhage," "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," 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.
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
Alice.
Webb
" FULL NAME
[If married or divorced woman or widow
give maiden name, aiso name of husband.]
@RESIDENCE
41 Eurde Rd. Il inetlist of
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
widow
· DATE OF BIRTH
2 1845
(Month)
(Day)
(Year)
7 AGE
22
3
mos.
.17
ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
at Home
(b) General nature of Industry, business, or establishment in which employed (or employer) ..
Central Hemorrhage
......
.(Duration)
.......... yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration) ................ yrs.
mos.
............ ds.
(Signed)
Edward Franiger,
M.D.
apr. 21, 1917 (Address)
49 Baulettood.
* If death followed injury or vioience 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.
Bellevue
Lawrence (amely
DATE OF BURIAL
4/23
1917
.......
Filed 191
......
.......
REGISTRAR
16 DATE OF DEATH
apr.
20
191.7
.......
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from apr.14
1917, to
apr - 20
199
If LESS than
1 day .........
hrs.
that I last saw her alive on
apr . 20
1919
. .
and that death occurred, on the date stated above, at
....... m.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
England
PARENTS
12 MAIDEN NAME
OF MOTHER,
Elizabet Namen
1ª BIRTHPLACE
OF MOTHER
(State or country)
England
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Town longe :.
(Address)
41 Brach Rl
(No. +1Buch Rd.
St. ;..
Ward)
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
20 UNDERTAKER G.R. Bermusma
ADDRESS
Hinter
4
7
10 NAME OF
FATHER
non Ceece
6
11 BIRTHPLACE
OF FATHER
(State or country)
England
.... www ..... yrs.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precisc 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 engincer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborcr, 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 oceu- pation whatever, write None.
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