USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 62
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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- pcumonia ("Pneumonia," unqualified, is indefinite) ; Tuher-
1
- -
- - .
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 disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing deatlı), 29 ds .; Broneho-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 discase can be ascertaincd 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, 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.
[12-'15-XXM.]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No. 218 Cliffctor St. ;. ......... .Ward) .....
Unsitiop
BOSTON
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Bertha Lee Tackar
[If married or divorced woman or widow give maiden name, also name of husband .! @RESIDENCE 218 Cliff avr
bordegood wife of William
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
* SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
marked.
16 DATE OF DEATH
May 18
...
191
(Month)
(Day)
(Year)
· DATE OF BIRTH
Rcf 14-1860
(Month)
(Day)
(Year)
7 AGE 57 yrs 8 .
mos. ds.
Or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work .......
Stourecoge
(b) General nature of industry, business, or establishment In which employed (or employer) ....
9 BIRTHPLACE
(State or country)
London 7. 7.
PARENTS
12 MAIDEN NAME
OF MOTHER
LucianLucent
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Zum Tasker
(Address) 218 Cliffcz
16
Filed
191
REGISTRAR ....
17
I HEREBY CERTIFY that I attended deceased from
March 26, 1917, to Mars 18
1912
that I last saw her alive on
May 17
1917
and that death occurred, on the date stated above, at 3-40P. m.
The CAUSE OF DEATH* was as follows :
Chronic Endocarditis
Did a surgical operation precede death ?
No Date
.(Duration)
1
mos.
ds.
.... yrs.
Contributory Chronic Interstitial Nephritis
(SECONDARY)
.(Duration)
yrs. .....
mos.
.. 2.2 .... ds.
Coleman Brown
(Signed)
........
...
M.D.
May 19, 1917 (Adres).
27 Central Sq
arzata
* 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. ............ ds .__..........
In the
Where was disease contracted, If not at place of death ?....
Former or 218 (luft (eur)
usual residence
19 PLACE OF BURIAL OR REMOVAL Pittsfield 7. 78
DATE OF BURIAL
7/22
191
... .
ADDRESS
20 UNDERTAKER Cap Pollici
22
10 NAME OF
Tham Olegood
A BIRTHPLACE OF FATHER (State or country) -n. f.
If LESS than I day ......... hrs.
OUI L
7 18/19/7
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 eaclı 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 cxamples: (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. - 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: 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, peritonaeum, etc., Careinoma, 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," "Scnile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage,", "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 dcath upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Newfoundland .
12 MAIDEN NAME
OF MOTHER
Eliza Dame.
13 BIRTHPLACE
OF MOTHER
(State or country)
Newfoundland.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
19 butes Ir Wintture Woodlawn
(Address)
Filed
191
REGISTRAR ....
MEDICAL CERTIFICATE OF DEATH
3 SEX Male
' COLOR, OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the word)
Married
· DATE OF BIRTH
15
185 !?
(Month)
(Day)
(Year)
7 AGE
If LESS than 1 day ........ hrs.
61 yra. 9 mos 3
ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Shih Carpenter
(b) General nature of industry, business, or establishment in which employed (or employer) ..
Cavotec ..
(Duration)
... yrs.
...........
mos.
/ da.
Contributory
Carmona pittural
.. (Duration)
yrs.
mos.
ds.
Muren
M.D.
(Signed)
May 19. 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).
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 2 Pm May 2/ 1917
20 UNDERTAKER
ADDRESS
E. G Brownton East Breton
18
>
-
191.
....
(Month)
(Day)
(Year)
....
191.
... ;
to ..
attended deceased from
I HEREBY CERTIFY that
4
Way 18
7
191.
.......
191.
that I last saw he
alive on
Way /18
2
.......
and that death occurred, on the date stated above, at ...
...... m. The CAUSE OF DEATH* was as follows : Hamonbags Intercal
(City or town.)
[If death occurred in a hospital or instituticn. give its NAME instead of street and number.]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH Winttolo (No .... 19
Center
St. :
...... Ward)
Silas
Taylor
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 19 Center Sr Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
May
9 BIRTHPLACE
(State or country)
" Newfoundland.
10 NAME OF
FATHER
Abram Taylor.
18 1
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, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, ete. But in many eascs, 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 laborer, Laborer - Coal minc, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who reecive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At homc. Care should be taken to report specifically the oceupations 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 fact may be indieated thus: Farmer (retircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affeetion with respect to time and eausation), using always the same aeeepted term for the saine disease. Examples: Ccrebro-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, 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 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," 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, 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 street, or one supposed to be due to Alcoholism, etc.
4. Deaths under eireumstances unknown, as A person found dead, etc.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1917.
CITY OF BOSTON
TOBIAS SWENSON
FULL NAME
Place of Death ¿
Boston
and Residence (
Date of Death
MAY 22
1917,
Age
54
years 6
months
17
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
M
Maiden Name
Husband's Name
R
RISUS Primary JE (Duration)
ROBIS
Name of Father
SWEN SWENSON
CONDITAA
2. 1822
Birthplace
of Father
NORWAY
ST
. MASS.
-
Maiden Name of Mother
Birthplace of Mother
NORWAY
Occupation
ENGINEER ( STEAM)
MAY 23 1917
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
WINTHROP ( WINTHROP CEM) Usual Residence
WINTHROP ( 10 VINE AVE)
Undertaker
W. C. SKAGGS
Filed
MAY 26 1917.
A true copy. Attest :
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 :
R
R
SEPTICAEMIA -PRESUMABLY FOLLOW-
Birthplace
NORWAY
CITY
ING AN INFECTION OF LEFT HAND
BOSTONIA
8 IMINE DONATA A
Contributory: (Duration)
ANNA GAFSIELSEN
(Signed)
W.H.WATTERS MED.EX. M.D.
Informant
MASS. HOMEO.HOSPT.
Registered No.
5628
Registrar.
may 22, 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 .... 257 ...
St. :
Ward)
2 FULL NAME
Catharina . Wadsworth
Josselyn. John Nadsurth
{If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 257 Milhoto Sti Wathope
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
W
· SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widound
· DATE OF BIRTH
8 (Month)
23
1826
(Year)
7 AGE
....
If LESS than
[ day ........ hrs.
min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
к .....
Houseof
(b) General nature of industry, business, or establishment i which employed (or employer).
9 BIRTHPLACE
(State or country)
Duxbury Man
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country
Hanson, mais
12 MAIDEN NAME
OF MOTHER
Catharina Pierce
18 BIRTHPLACE
OF MOTHER
(State or country)
Duxbury, Mais
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Lus. Wood
(Address)
257 Withrate St
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
1
(Day)
24
, 1912
........
(Year)
17
I HEREBY CERTIFY that I attended deceased from
May 15
191.2 .... , to
may 24"
191.2 ....
that I last saw hem alive on
May
24
, 1917.
and that death occurred, on the date stated above, at,
11.15Hm.
The CAUSE OF DEATH* was as follows :
Lobar
Pneumonia
(Duration)
......
.yrs.
........
mos.
9
ds.
Contributory (SECONDARY)
(Duration).
.. mos. ................ ds.
yr&
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).
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
mayflower 5-28-197
20 UNDERTAKER W.C. Skaggs
ADDRESS
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.}
-
(Day)
90 yrs 9 mos. 1 ds.
10 NAME OF
FATHER
Calvin Joscelyn
(Signed)
26. 1917 (Address)
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 necded. 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 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 Houscwife, Housework, or At home, and children, not gain- fully employed, as At sehoo' or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Scrvant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retircd, 6 yrs.). For persons who have no 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: Ccrcbro-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," unqualificd, is indefinite) ; Tuher-
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," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "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 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Marion J. Low
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 60 Cliff Que
PERSONAL AND STATISTICAL PARTICULARS
1 PLACE OF DEATH
Munchrot
(No ...
2 FULL NAME
3 SEX
Temario.
4 COLOR OR RACE
voluto
§ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
" DATE OF BIRTH
(Month)
(Day)
7 AGE
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer).
12 MAIDEN NAME
OF MOTHER
PARENTS
.
18 BIRTHPLACE
OF MOTHER
(State or country)
(Informant)
Shiny Clark
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
....
04, 9 26
ds.
widow
,853
1
(Year)
If LESS than day ........ hrs.
or ........ min. ?
9 BIRTHPLACE
(State or country)
Falopolice Ohio
10 NAME OF
FATHER
10m 13. Clark
11 BIRTHPLACE
OF FATHER
(State or country)
Wheeling TU.Va
Wheeling 20.Va
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)
60 Cliff are Visitant
Filed 191
REGISTRAR ........
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
7
. Men 31
191
..... .
that I' last saw h Dalive on May 29 1917 m. and that death occurred, on the date stated above, at 5 0
The CAUSE OF DEATH* was as follows :
mos, ...............
ds.
Contributory Acute Franstotal Wattos
.........
(SECONDARY)
A .. (Duration)
/
yrs.
mos. ds.
(Signed)
5/31
1917
191 ....... (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).
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
Woodlawn Everitt Gens
DATE OF BURIAL
June 4 1912
20 UNDERTAKER
ADDRESS
-
(City or town.)
St .... Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
31
(Month)
(Day)
191 (Year)
....
....
.....
Widow of Calin P. Low
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, Architcet, 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," ete., 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 rceeive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
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