USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 69
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
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 dcad, etc.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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
15-'17-XXNt.|
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
Winthrop
(No.
131 Winthrop At St.
....... Ward)
John W. Richards
* FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
131 Winthrop LA Registered No, ....
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
COLOR OR RACE
White
5 SINGLE.
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
Manning
& DATE OF BIRTH
(Month) (Day)
1
(Year)
7 AGE
If LESS than
I day ......... hrs.
75,
.. yrs.
mos.
ds.
Or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work .......
Retired Fianco Many
(b) General nature of Industry, business, or establishment In which employed (or employer).
9 BIRTHPLACE
(State or country)
JOVEN S.H.
PARENTS
LI BIRTHPLACE
OF FATHER
(State or country)
Unknown
12 MAIDEN NAME
OF MOTHER
adeline Watson
13 BIRTHPLACE
OF MOTHER
(State or country)
Unknown
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
muletas Saunders
(Address)
95 milk st
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Month)
(Day)
,
(Year)
17
Och.
6
to
July
1917
....
that I last saw hice
alive on
1
1917,
and that death occurred, on the date stated above, at.
6. Q m.
The CAUSE OF DEATH* was as follows :
Canen 1 intestine with lemonhang
Did a surgical operation precede death ? Le Date Nov. 19/6 22 For. 1911 for recurrent of total cauces 18%
(Duration)
yrs.
„mos.
ds.
Contributor Canen y Tonsil
IfForund Cet. 1916
.(Duration)
(Signed)
Guttin K. Vloni
M.D.
Aus 4, 1917
(Address)
44 Fairfield SI-
....
* 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
Laurence Mark Ung 7, 1917
NU UNDERTAKER
IS Waterman Send
ADDRESS
2326 Wack It
BOSTON
(City or town.) [If death" occurred in a hospital or institution, give its NAME instead of street and number.]
191
I HEREBY CERTIFY that I attended deceased from
.... yrs.
... mos. ................ ds.
John M. Richards
aug. 4, 1917
STANDARD CERTIFICATE OF DEATH.
,
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can bo known. The question applics 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 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 bo used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. Tho material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dcaler," etc., without more precise specification, as Day laborcr, Farm laborer, Laborcr - Coal minc, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definito salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At sehoo' or At homc. 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 (rctired, 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 same diseasc. 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," unqualificd, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of. ........ (namo origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasıns) ; Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Scnile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old agc," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases 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 tho 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 discasc, 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.
R. 15. 1-'17. 100,000.
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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Catherine
Groenewald
'FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Winthrop. Mars.
unknown Jacob
.... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1ª DATE OF DEATH aug 4 ....... 191.7
(Month)
(Day)
(Year)
· DATE OF BIRTH
9
22
(Month)
(Day)
., 1841 (Year)
'AGE
If LESS than 1 day ......... hrs.
76 yrs. 10 mos.
12
ds.
„min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
athome
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Germany.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
2
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
Финали
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
W. W. Heckman
(Addres
2) 321 pleasant St
15
Filed ., 191
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from may
191.2.
., to.
4
1917
that I last saw hle
alive on
1917
and that death occurred, on the date stated above, at 7.30 pm
The CAUSE OF DEATH* was as follows :
Cestino Belevenis
Contributory
(SECONDARY)
(Duration)
yrs.
.. mos. ds
(Signed)
M.D
......
1917 (Address) 218 hiamb
* 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.
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 Dayton Ohio
DATE OF BURIAL
191.Z
20 UNDERTAKER
W.S. Skaggs
ADDRESS
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
1 SEX
fr
4 COLOR OR RACE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
& SINGLE Word
......
St. :
..... ............. Ward)
....
.(Duration)
................ yrs. ................ mos. ......... ds.
10 NAME OF
FATHER
.......
(No. 321 Pleasant
ang. 4, 171/
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 occupation 3 a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engincer, 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 ncedcd. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepcrs who receive a definite salary), may be entered as Houscwife, 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 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 (rctircd, 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: Ccrcbro-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) ; Tube :-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, ctc., 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," "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, Suicidc, 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 strcet, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dcad, etc.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH 1917.
CITY OF BOSTON
Registered No. 8045
Place of Death ¿
Boston
and Residence (
Date of Death
AUG 8
1917, Age 30
years months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
MARRIED
I HEREBY CERTIFY that | 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 :
Maiden Name
Husband's Name
WILLIAM PAYNE
Birthplace
Name of Father
PATRICK CASS
Birthplace of Father
ENGLAND
Maiden Name of Mother
ELIZABETH
Birthplace of Mother
IRELAND
Occupation
AT HOME
AUG 8
1917
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal MALDEN (HOLY CROSS)
Undertaker
W.J. CASSIDY BOSTON
Usual
Residence WINTHROP (229 SHIRLEY ST)
Filed
AUG 13
1917
A true copy. Attest :
Registrar.
CHR. MYOCARDITIS
CITY
ASICI
MOBIS
DOFFICE
BOSTONIA
JA A. 1822.
STON.
Contributory: (Duration )
-
(Signed)
GEORGE H. STONE M. D.
Informant
PHYSICIAN'S CERTIFICATE.
R
STRAR' PATKIBUS Primary M/s (Duration
BOSTON NASS
CTVYTATIS CONDITAA USREGIMINE DONATA B MASS. 10 30.
FULL NAME
MARY G. PAYNE
PETER BENT BRIGHAM HOSP.
CASS
ung
1
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 occupation ? 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) Salcs- man, (b) Groecry; (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 DEATHI (the primary affection with respect to time and causation), using always the same accepted term 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, peritoneum, etc., Carcinoma, Sar- coma, etc., of ... ....... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasnis) ; 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 .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mercly symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify al. diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," ete. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- ... sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners: ;
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc
4. Deaths under circumstances unknown, as A person found dead, etc.
R '8. 1'17. 10,000.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1917.
CITY OF BOSTON
FULL NAME FREDERICK P. JORDAN
Registered No. 8165
Place of Death l
Boston
and Residence S
Date of Death
AUG.12
1917, Age 53
years
4
months 14
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
S
Maiden Name
Husband's Name
Birthplace
CHARLESTOWN
Name of Father
DAVID JORDAN
Birthplace of Father
WISCASSET .ME.
STON.
Contributory: (Duration)
Maiden Name of Mother
MARY L.REED
Birthplace of Mother
BOOTHBAY .ME.
(Signed)
G.H. STONE
M. D.
AUG. 13 1917
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT.6 MOS.+
Place of Burial or removal
WOOLWICH.ME.
Undertaker
W.C.SKAGGS
Filed
AUG.16 1917.
A true copy. Attest :
ENMGlenen
WINTHROP
PHYSICIAN'S CERTIFICATE.
1 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 :
RAR PATRIBUS Primary Tu (Duration)
PERNICIOUS ANAEMIA
R
CITY
BORIS
OFFICE
CIVITATI
BOSTONIA
CONDITA AL.
TA A 1822.
P 1831. REGIMINE DONATA A MASS.
Occupation
CARPENTER
Informant
Usual
Residence
WINTHROP (42 LEWIS AVE)
Registrar.
PETER BENT BRIGHAM HOSPT.
aug. 12, 1917
U
.
1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No. 103. River Road
St. ......... .Ward)
Stephen Granville J'ord-
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 103 River Road- Winetheok
PERSONAL AND STATISTICAL PARTICULARS
3 SEX male
A COLOR OR RACE
write
6 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
@ DATE OF BIRTH Sckl
2 /
(Month) (Day)
(Year)
7 AGE
55
60065 yrs ...
10
mos.
17
.ds.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
descène, presumably Coronary
(Duration) yrs.
mos. ds.
Contributesudden death )
(SECONDARY)
(Duration)
yrs.
mos.
ds.
Burgers Magrath
.,
M.D.
aug. 139. (Address). MEDICAL EXAMINER
* State the DISEASE CAUSING DEATII, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
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
Here. 15.
191
7
20 UNDERTAKER
ADDRESS
Filed
., 191 ..
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH Quan 13 H 1917 (Year)
(Montlı) (Day)
1861 17 I HEREBY CERTIFY that I have investigated the death of the deceased.
If LESS than 1 day, hrs. The CAUSE OF DEATH* was as follows : ...? Natural Causes; Cardiovascular
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Red Beach Maine
10 NAME OF
FATHER
William H. Ford
PARENTS
11 BIRTHPLACE OF FATHER (State or country) neue Breensuite
12 MAIDEN NAME OF MOTHER Either H. Birrokas,
13 BIRTHPLACE OF MOTHER (State or country)
Robbinzon Maine
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Horace 21. Ford
(Address)
mircertain Ave . Il Male.
16
b. E. Henderson ali Enenext
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.
9048 Winthrop (City or towi) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
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 occupation ? 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 dutics of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in 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 the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid usc 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 (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 septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."
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.