USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 58
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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-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- eoma, 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 (sccond- ary or intercurrent) affection nced 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.
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 discase, 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
.. (NO .... 16 Machungton Cer st.
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
" FULL NAME
Mendal Famkam
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 16 Hiashun ston and Wenthusk Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
married
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
Och
3 (Month)
(Day)
1848 1 (Year)
7 AGE 79
9
If LESS than [ day ......... hrs.
or ........ min. ? -
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of Industry,
business, or establishment In
which employed (or employer)
Trammig Contractor
9 BIRTHPLACE
(State or country)
"Combust Maso
PARENTS
12 MAIDEN NAME
OF MOTHER
Adelina, Fuller.
18 BIRTHPLACE
OF MOTHER
(State or country)
Dublin N. H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Eliza. J. Bristot
(Address)
16
Filed
191
REGISTRAR
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
1915
191
....... , to
may
....
-
1917
that I last saw him alive on
april 30
1912.
and that death occurred, on the date stated above, a 0.30 Pm.
The CAUSE OF DEATH* was as follows : General artoni Delensio
apoplex y (Cerebral Humorchange)
(Duration)
2 yrs.
........
.mos. ................ ds.
Contributory.
(SECONDARY)
(Duration)
yrs.
.......
.mos.
2
ds.
"(Signed)
31 Dulany
M.D.
... .
1917 (Address)
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death ............ yrs.
mos.
ds.
State ............ yrs.
.......
mos.
In the
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Cambudge Connely
DATE OF BURIAL
May 4th 197
ADDRESS
20 UNDERTAKER C .R. Benuson
(Month)
(Day)
1917
....
(Year)
yrs.
mos.
Retence
ds.
Uraettiste
10 NAME OF
FATHER
11 BIRTHPLACE OF FATHER (State or country)
....... ds ..............
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to 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 engincer, Civil cngincer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Namc, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for tlie same disease. Examples: Cercbro-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 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 (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," 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 21 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- 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 dead, etc.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1917.
CITY OF BOSTON
FULL NAME
FRANCES B. BURRILL
Registered No. 4790
Place of Death {
and Residence §
Date of Death
MAY I
1917,
Age
29
years months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
M
CHASE
Maiden Name
Husband's Name
CHARLES BURRILL
Birthplace
BOSTON (EAST)
Name of Father
JONATHAN CHASE
Birthplace of Father
HARWICHPORT
Maiden Name of Mother
ALICE A.WILSON
Birthplace of Mother
(Signed) G.H.STONE M.D.
MAY I 1917
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT. 17 DAYS
Place of Burial or removal
WINTHROP (WINTHROP CEM.)
Usual Residence
WINTHROP ( 15 BELCHER ST)
Undertaker
W.C.SKAGGS
Filed
MAY 4
1917.
WINTHROP
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 :
TRAR
PATRIBG
Primary
RI
(Duration
CITY
SICU
SAOBIS A
BOFFICE
2 1-2 MOS.
BOSTONIA CONDITAA
2.1822.
ISREGIMINE DONATA A BOSTO 1630.
MASS.
Contributory : (Duration )
Occupation
HOUSEWIFE
Informant
TOXAEMIA OF PREGNANCY
A true copy. Attest :
Registrar.
-
PETER BENT BRIGHAM HOSPT.
Boston
2
may 1,1917
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 .....
.... .
89
Summeet Que
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
[If married or divorced woman or widow give n @RESIDENCE
Summit Gul.
.......
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
· DATE OF BIRTH
12 (Month)
31
1837 (Year)
7 AGE
If LESS than day, .. hrs.
79 yrs. 4
„.mos.
.. min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
athome
...................
(b) General nature of industry, business, or establishment ín which employed (or employer) ......
9 BIRTHPLACE
(State or country)
" Lubec quer-
PARENTS
12 MAIDEN NAME OF MOTHER annie Bation
1ª BIRTHPLACE
OF MOTHER
(State or country)
Edison Mr.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Nuo Isreal Woodside
(Address)
8 9 Sement aus
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Muay
Month)
2
(Day)
1919 (Xear)
I HEREBY CERTIFY that I attended deceased from
17
Jany 8, 1917, to
May 1
1915
that I last saw h be alive on
1913
..... .
and that death occurred, on the date stated above, a
m.
The CAUSE OF DEATH* was as follows :
Carcinoma of
Ofall Bladder
about
1
(Duration)
-
..... mos. ................ da.
Contributory
(SECONDARY)
.(Duration)
yrs.
mos.
.......
ds.
(Signed)
May 3, 1913 (Address) Winstrofrears
* 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 ............ y:s. ....
In the
mos.
.........
ds ............
Where was disease contracted, if not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
Woodlawn
DATE OF BURIAL
5-5
1917
2 UNDERTAKER
W.C. Skaggs
ADDRESS
=
10 NAME OF
FATHER
Greenlief Wiggins
11 BIRTHPLACE OF FATHER (State or country) china ME.
(Day)
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," ctc., without more precise specification, as Day laborer, Farm laborer, Laborer -- Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.
Statement of cause of death. - Namc, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the sanie diseasc. Examples: Cerebro-spinal fever (the only definite synonyın 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 (sccond- 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 discascs resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N B - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See Instructions on back of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Frost Hospital
(No.
Chelsea , Mass.
St. ;........................ Ward)
(City or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Georgina B. lis yberry
-
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 224 Court Road, Winthrop, Mess.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Marr.
(Month)
(Day)
.....
(Year,
· DATE OF BIRTH
Feb. 10, 1804
(Month)
(Day)
1
(Year)
TAGE
If LESS than
I day ......... hrs.
50
2
mos.
22
ds.
.min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Housewife
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
Ovaries
(Duration) ... yrs. m ............ mos .......... .. de.
Contributory
(SECONDARY)
(Duration)
Ys. -- - mos.
.de.
.........
(Signed)
Harvey A. Kelly
M.D.
May 3. 19 7
(Address)
200 Pleasant St.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
13 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
in the
At place
of death ............ yrs ..
-
nos.
7
ds. - State ..........
....... yrs.
........ mos. ............ ds .............
Where was disease contracted,
If not at place of death ?...
Former or
224 Court Rd. Winthrop
19 PLACE OF BURIAL OR REMOVAL Winthrop Cer .
DATE OF BURIAL
May 6,'17
191
(Address)
Winthrop, Mass.
16 Filed May 3, 19175
· REGISTRAR
17
I HEREBY CERTIFY that I attended deceased trom
Nov.
to
1916
kg y 3'17
191
that I last saw h.Q ..... alive on.
191
and that death occurred, on the date stated above, at 2 Pm.
The CAUSE OF DEATH* was as follows :
Carcinoma of Stomach
9 BIRTHPLACE
(State or country)
Cape Neddick, Me.
10 NAME OF
FATHER
John J. Hibbert
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Er gland
12 MAIDEN NAME
OF MOTHER
Unknown
18 BIRTHPLACE
OF MOTHER
(State or country)
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
A. R. Bennson
usual residence ..
20 UNDERTAKER
C. R. Bennison
ADDRESS
Winthrop
191
13 DATE OF DEATH
May 3 1917.
Registered No. 314
5.191%
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 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) Salcs- 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 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 Nonc.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATII (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 rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, is indefinite) ; Tubcr-
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: Mcaslcs (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," "Marasınus," "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 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 deathis of persons not disabled by recognized disease, as A death upon the street, or onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dcad, etc.
R 18. 1.'17. 10,000.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should stato 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.
[10-'16-XXM.]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1
PLACE OF DEATH
(No
62 Uhrotra QUE
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
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
62 Chrotos aus
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
* SEX
' COLOR OR RACE
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Marisa
$ DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
I day ......... hrs.
or ... .min. ?
· OCCUPATION
(a) Trade, profession,
particular kind of work
Piano Manstrachin
(b) General nature of Industry
business, or establishment
which employed (or employer)
9 BIRTHPLACE
(State or country)
PARENTS
12 MAIDEN NAME
OF MOTHER
Margaret Luffy
13 BIRTHPLACE
OF MOTHER
(State or country)
Island
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address)
la thestr auz
15
Filed
, 191
.....
REGISTRAR
16 DATE OF DEATH
(Month)
3
(Day)
1917
....
17
I HEREBY CERTIFY that I attended deceased from
april 26
191,2 .... , to
191
may/30
1917
and that death occurred, on the date stated above, at 8 08 /1
3
2 30
)
that Y last saw Ami
alive on
The CAUSE OF DEATH* was as follows :
Lobay Prawny
Did a surgical operation precede death ?
Date
.(Duration)
............ yrs.
... mos.
7
ds.
Contributory.
(SLCONDARY)
{Duration).
........ yrs. ......
mos.
...............
da
(31 Dular)
M.D.
(Signed)
Jay 3, 1917 (Addres)
* If death followed injury or violence the certificate of defuh must be made ont 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
19 PLACE OF BURIAL OR REMOVAL
assphi
20 UNDERTAKER
ADDRESS
I/ O leased 160 Harrison
DATE OF BURIAL
Mays
7
191
...
10 NAME OF
FATHER
Daniel
11 BIRTHPLACE
OF FATHER
(State or country)
Irland
( Year)
...
yrs.
mos.
ds.
..........
1
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preeise statement of oeeu- 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 engincer, Civil engineer, Stationary fireman, etc. But in many eases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise 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, ete. If the oceupation 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 (rctired, 6 yrs.). For persons who have no oeeu- pation whatever, write Nonc.
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