USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 59
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Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same diseasc. Examples: Cerebro-spinal fevcr (the only definite synonym is "Epidemie eerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, 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 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," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., when a definite disease ean be aseertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," ete. State eause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ete
4. Deaths under eireumstanees unknown, as A person found dcad, ete.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No.
48
Madigno an
St. : ...... Ward)
Charles Hadley Bunks.
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 48 modiano ar Manttirolo.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
While-
20
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
single.
· DATE OF BIRTH
Sept 5 str 1916
(Month)
(Day)
1
(Year)
7 AGE
X Jr. 7
.yrs.
mos.
30
ds.
Or ......... min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Winthrop Maso:
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Graffitury 21.
12 MAIDEN NAME
OF MOTHER
Many I Hawkins.
1ª BIRTHPLACE OF MOTHER (State or country)
Pensacola Florida.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ...
totales Ht. Bundes.
(Address)
168 Madison ave Mintis
16
Filed
191
FEGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
may
3
19111
....
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
april 20
1917, to
may 30
1912.
1
..
that I last saw him
alive on
hin 3
1917
and that death occurred, on the date stated above, at ..
230 Am.
The CAUSE. OF DEATH* was as follows :
Whoofma Cough
(Pertussis)
... (Duration) .
............... yrs. ..............
.. mos.
14
ds.
Contributory
(SECONDARY)
(Duration)
... yrs.
mos. ............
ds.
031 Metcalf
M.D.
(Signed)
hay 30
19!
7 (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).
In the
At place
of death
. yrs.
mos.
ds.
State
.yrs.
mos.
ds ............
Where was disease contracted, if not at place of death ?.
Former cr usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL I intherh Cemelant the, May,41917
20 UNDERTAKER
ADDRESS
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
....
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.
10 NAME OF
FATHER
Charles H Berufs.
If LESS than
l day ........ hrs.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- 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, 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 nceded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who reccive 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 diseasc. 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" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Dcbility" ("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 septieaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized diseasc, 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
Winthrop Plus
(No
16 Washington cover
St. ;........ .. Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Isabella, Farnham
Widow of George . Y. Farinham
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
16 Washington une Mentetiona 20 ans
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
widow
$ DATE OF BIRTH
enural
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day ......... hrs.
81
Lyrs ._
... yrs.
mos.
13
ds.
„min. ?
B OCCUPATION
(a) Trade, profession, or
particular kind of work
int- troms
(b) General nature of industry,
business, or establishment
which employed (or employer)
9 BIRTHPLACE
(State or country)
Ireland
PARENTS
12 MAIDEN NAME
OF MOTHER
unfinom
13 BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
CRBBennon
(Address)
Wencheoch Ilor
16
Filed
191
REGISTRAR
Som y
www ... yrs.
mos.
...........
ds.
Contributory
(SECONDARY)
chf
(Duration) يـ
+
mos. ............
ds.
(Signed)
4
1917
(Address).
Ichamb
* If death followed injury or violence the certificate of death must be made ont by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
In the
At place
of death.
.......
.. yrs.
.. mos. ...
„ds.
State ............ yrs. ............. mos.
.......... ds ............
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Cambridge Candy May 8
... .
191.7
20 UNDERTAKER
ADDRESS
---
16 DATE OF DEATH
May
G
1917
....
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
March
...........
1917,to
They J. 19/17
that I last saw h
alive on
191.
..... ,
and that death occurred, on the date stated above, at ...
9pm.
The CAUSE OF DEATH* was as follows :
chra
Endocarditis
10 NAME OF
FATHER
Richard Demean
11 BIRTHPLACE
OF FATHER
(State or country)
1836
...
(City or town.)
.......
STANDARD CERTIFICATE OF DEATH. 111%
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulncss 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 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 uceded. 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 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 Nonc.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to tine and causation), using always the same accepted terin for the same discase. 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 ncoplasms) ; Measles; Whooping cough; Chronic valvular heart discasc; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection necd not be stated unless im- portant. Example: Mcasles (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," "Dcbility" ("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 septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, ctc.
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
Winthrop
(No.
63 Waldemar, west .;
-
Lais mc nish.
*FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
63 Waldemar ave Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
I SEX
Female
4 COLOP OR RACE
SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the wordferiale)
1ª DATE OF DEATH
Way
5, 1917
(Day)
(Month)
(Year)
' DATE OF BIRTH
February 24 1917
(Month)
(Day)
(Year)
· AGE
If LESS than 1 day ......... hrs.
... yrs. ................ mos.
ds
or.
min ?
· OCCUPATION
(a) Trade, profession, or
particuler kind of work
22
and
(b) General nature of industry. business, or establishment in which employed (or employer).
Meningitis
9 BIRTHPLACE
(State or country)
Chelsea mass
PARENTS
12 MAIDEN NAME
OF MOTHER
Evelyn Woodbury
13 BIRTHPLACE
OF MOTHER
(State or country)
Roxbury mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
John & mc heesh
(Address)
Winthrop mass
16 Filed 191
REGISTRAR
(Duretion)
yrs.
mos.
£
ds.
Contributory
Umbilical infection
(SECONDARY)
.(Duration)
yts.
2 mos. ......... ds
(Signed)
SeomBienwick
...
M D
Want, 199
(Address).
24 gardner Chelsea
* 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 deeth.
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 Glenwood
DATE OF BURIAL
Imay 6, 19/7
20 UNDERTAKER
coff aunce
ADDRESS
Chelsea
Ward)
.....
Winthrop
(City or town.) [If death occurred ir a hospita or institution, give its NAME instead of street end number.]
17 I HEREBY CERTIFY that I attended deceased from
, 1917, to
1912
that I last saw her
alive on
man 4
1917
and that death occurred, on the date stated above. at.
11
Am
The CAUSE OF DEATH* was as follows :
10 NAME OF
FATHER
John Ancheish
11 BIRTHPLACE
OF FATHER
(State or country}
Chelsea mass
Female
4 STANDARD CERTIFICATE OF DEATH. 1
Statement of occupation. - Precise statement of oecu- 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 occupation 3 a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive cngincer, 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, 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 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 eausation), 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: "Caneer" is less definite; avoid use of "Tumor" for malignant ncoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age,". "Shoek," "Uraemia," "Weakness," ete., when a definite disease ean be aseertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State eause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the strect, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
3 SEX Damals 7 AGE PARENTS 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
Winthrop
(No.
1
Winthroke Show Drive.
Ward)
(City or town.) [If death occurred in e hospital or institution, give its NAME Instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
+ COLOR/OR RACE
chehita
& SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
Married
DATE OF BIRTH
(Month)
(Day)
(Year)
If LESS than
! day ........ hrs.
----. yrs.
mos.
10
ds.
or ......... min. ?
3 OCCUPATION
(a) Trade, profession, or
particular kind of work
at home
(b) General neture of Industry,
business, or establishment In
which employed (or employer)
9 BIRTHPLACE
(State or country)
Ihaceachusetts
10 NAME OF
L
FATHER
Brad Morrich
11 BIRTHPLACE
OF FATHER
(State or country)
truth raton
12 MAIDEN NAME
OF MOTHER
Wander Fratries Titus
13 BIRTHPLACE
OF MOTHER
(State or country)
New Brunswick.
14 THE ABOVE IS, TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Elavance Moffat Hoch ridge
(Address)
1 Ahora Hours, Hvithusk
16 Filed ., 191
.......
REGISTRAR -...
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
May
7, 1919
....
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
............
14, 1919.
to
.......
..........
.......
191
that Hast saw h .......
alive on
6806
m.
The CAUSE OF DEATH* was as follows : Piermia (Inscritas delivery
Felly 14 1967 )
Did a surgical operation precede death ? yes Date april 20,
(Duration)
5 yrs. 2 mos. 23 ds.
Contributory.
(SECONDARY)
X
(Duration)
... yrs.
.. mos. .............
„ds.
(Signed)
M.D.
May 8, 199
(Addrass)
Светивер Таля
.....
* 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.
............ moz.
..........
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 Nicolas Cemetery
DATE OF BURIAL
May 9, 1917
ADDRESS
20 UNDERTAKER
Johnle Bancheluck
...........
Mrs. Carry TEather Marich Hochiday " FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 1 Shore Minh: Grin
Claramen Naflat Hiciera i.s. F( Husband)
winthrop BOSTON
21
yra. 4 mon
at homini
and that death occurred, on the date stated above, at
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- 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, Arehiteet, Loeo- motive cngincer, Civil engineer, Stationary fireman, ete. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborcr, 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, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that faet may be indicated thus: Farmer (rctired, 6 yrs.). For persons who have no oeeu- pation whatever, write None.
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