USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 6
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93 | Part 94 | Part 95 | Part 96 | Part 97 | Part 98 | Part 99 | Part 100 | Part 101 | Part 102 | Part 103 | Part 104 | Part 105 | Part 106 | Part 107 | Part 108 | Part 109 | Part 110 | Part 111 | Part 112 | Part 113 | Part 114 | Part 115 | Part 116 | Part 117 | Part 118 | Part 119 | Part 120 | Part 121 | Part 122 | Part 123 | Part 124 | Part 125 | Part 126 | Part 127 | Part 128 | Part 129 | Part 130 | Part 131 | Part 132 | Part 133 | Part 134 | Part 135 | Part 136 | Part 137 | Part 138 | Part 139 | Part 140 | Part 141 | Part 142 | Part 143 | Part 144 | Part 145 | Part 146 | Part 147 | Part 148 | Part 149 | Part 150 | Part 151 | Part 152
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, 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senilc," 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 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. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, E.c- 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.
The Comumnomwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH - . Winthrop (No. 49 Arianne 21 St. :
....... 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 maiden name, also name of husband.]
aRESIDENCE 49 Milani di
......
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) Neve E
· DATE OF BIRTH
HEN
5
,1916
(Year)
(Month)
(Day)
7 AGE
If LESS than
! day ......... hrs.
.. yrs. mos. ds.
or ....... min. ?
* 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)
10 NAME OF
FATHER
Opravco / 1/ 2)
1
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER
18 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address) 49 cotto 120 2
16
Filed
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Feb.
(Month)
(Day)
5, 1916
(Year)
17 I HEREBY CERTIFY that I attended deceased from 191. ............... , to. 191
that I last saw h
....
alive on
191
.......
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Stilllow
.(Duration) .............. yrs. ................ mos. ................ .ds.
Contributory (SECONDARY)
(Duration) ... yrs. .......
mos. . ...... ....... ds.
(Signed)
Charles Fmaloney
M.D.
Jeb. 5
285 mnchenth st
191.6. (Address)
* 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).
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
DATE OF BURIAL
1€
-
E
.,
1915
20 UNDERTAKER
ADDRESS
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
PARENTS
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 cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, ctc. 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," etc., without more precise specification, as Day laborer, Farm laborer, Laborcr - 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 serviee 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 (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 "Epidemie ecrebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pucumonia"); 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); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affcetion 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," 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 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 eonditions 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 violenee, 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 eircumstances 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) 19 21000
12 MAIDEN NAME OF MOTHER Ruck Tyler
13 BIRTHPLACE OF MOTHER (State or country)
Somenice
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
CR Bemun
(Address)
nordland
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Mall
" DATE OF BIRTH
3 1916
(Month)
(Day)
(Year)
7 AGE
If LESS than I day ........ hrs.
.yrs.
...... 44 da. mos.
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)
(Duration). .ds. yrs. ............. mos.
Contributory.
(SECONDARY)
(Duration)
2
mos.
.......
... ds.
Aurin (el / ella
(Signed)
M.D.
9277, 1916 (Address) 200 Heart
[ ........
* 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.
In the
............ mos. .....
.......... mos.
ds.
State ...
.yrs.
ds ...... ....... Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
..... .
1916
........
ADDRESS
20 UNDERTAKER
e.R Ben
Whichit
.......
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Baby Bauer
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband).
@RESIDENCE
130
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
' COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
72%
(Month)
(Day)
6
1916 (Year)
17 I HEREBY CERTIFY that I attended deceased from 726 3 1916, to ..........
Ich6
96
that I last saw h ..........
alive on
1916
and that death occurred, on the date stated above, at
2Pm.
The CAUSE OF DEATH* was as follows :
Inanitim
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 130 Cerenet- Rcs.
Ward)
....
10 NAME OF FATHER Theodore E. Bauer
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- 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 engineer, Civil engineer, Stationary fireman, ete. But in many cases, especially in industrial employments, it is neecssary 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 inay form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specifieation, as Day laborer, Farm
1 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, Houscwork, 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 Scrvant, 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 (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 affeetion with respect to time and eausation), using always the same accepted term for the saine disease. Examples: Cercbro-spinal fever (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," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonaeum, ete., Carcinoma, Sar- coma, ete., of .. ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (second- ary or intereurrent) 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," ete., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or misearriage, 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 violenec, 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, etc.
4. Deaths under eireumstances unknown, as A person found dcad, 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)
Scotland
12 MAIDEN NAME
OF MOTHER
abramal
18 BIRTHPLACE
OF MOTHER
(State or country)
Scotland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
HiFi detson
(Address) 86 Bartlett Road
16
Filed 191
...
...............
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
9
1916
.......
(Month)
(Day)
(Year)
· DATE OF BIRTH
3 (Month)
13
(Day)
1839
(Year)
7 AGE
If LESS than [ day ......... hrs.
77 yrs.
10
mos.
26 ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work.
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
The CAUSE OF DEATH* was as follows : General cesterio schonis Calitation? Heart nutral requisgulation
(Duration)
.yrs.
6
...............
Contributory
(SECONDARY)
(Duration).
.......
.f. yrs. ...
mos. .
ds.
(Signed)
2010
191 ..... (Address)
M.D.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
IS LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ..
......... yrs. ............ mos.
ds.
State ............ yrs.
.......
In the
mos. ............ d.s .............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Chatham M.V3.
DATE OF BURIAL
2-13 - 1916;
.........
20 UNDERTAKER
H.C. Shu490
ADDRESS
Wintheol
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
Winthrop
(No 186, Bartlett Roast.
.................
....
Ward)
Isabellaf Letson
' FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chatham. 2.10.
Francis f. Letson-Ker
Winth o'
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
17 I HEREBY CERTIFY that I attended deceased from
1910
to.
1916
that I last saw h M alive on
191.
6
and that death occurred, on the date stated above, at.
9400 m.
....
........
mos. ds.
9 BIRTHPLACE
(State or country)
Chatham_ 4.3.
10 NAME OF
FATHER
George Kerst
....
Registered No.
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, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, ctc. 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," "Dealcr," ete., without more preeise 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 ehildren, 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 aecount of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that faet 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 eausation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic ecrebro-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, ete., 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, ete. The contributory (second- ary or intereurrent) affeetion need not be stated unless im- portant. Example: Mcasles (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," "Uraemia," "Weakness," etc., when a definite disease ean be aseertained as the cause. Always qualify all diseases resulting from childbirth or misearriage, 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 eaused by violenec, 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, 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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 11) Highland Chose: .Ward)
Edwin D. Green.
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of, husband ]
@RESIDENCE
117 Highland are Winthat
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Mais
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Singh
· DATE OF BIRTH
....
(Month)
(Day)
1
(Year)
7 AGE
25
.yrs.
........... mos. ds.
or .. min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
.....
..........
..... Septic Endocarditis
Did a surgical operation precede death .
Date
(Duration)
/
.. yrs.
mos.
ds.
ContriButory
Berefeel New genhagy
(SECONDARY)
.(Duration)
.. yrs.
.mos.
(Signed)
Dr.l. Parter
5
ds.
M.D.
Treba 9/ 1916 (Address)
Winthroto
* 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.
In the
mos.
ds.
State.
... yrs.
mos.
.......
Where was disease contracted,
If. not at place of death ?..
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Holy loan Malchin
DATE OF BURIAL
Fak 18
1917
.......
20 UNDERTAKER
P. G. Kinh
ADDRESS
Bagt
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Cash Baston
12 MAIDEN NAME
OF MOTHER
anime Roach
13 BIRTHPLACE
OF MOTHER
(State or cou
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Matter
(Address) 17 Highland Clan Ortach
Filed
191
REGISTRAR
00 454 Parent.
ROSTON ..............
(City or town.) Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
191.
(Montir) .
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Jan. 15, 19K,
to Ich, 9
19164
If LESS than
1 day .......
hrs,
that I fast saw
bien alive or
196
and that death occurred, on the date stated above, at 62 m. The CAUSE OF DEATH* was as follows :
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Chileca
......
10 NAME OF
FATHER
alexander
16 DATE OF DEATH
....
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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 ou 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. Thic 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. laboter, Løborers- Coal mine, etc. Women it home, who are engaged in the duties of the householl 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 AAt 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 persous who have no occu- pation whatever, write None.
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.