USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 73
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The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No. Nilshur ....
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Mary
Elizabet en kesbury
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] ........... @RESIDENCE 44 Weeshuis the Machen Registered No. MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
4 COLOR OR RACE
§ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Lenja
S DATE OF BIRTH
Cech
251836
1
(Month)
(Day)
(Year)
7 AGE
PO yra. 18 mos 5
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).
chool Kachun
9 BIRTHPLACE
(State or country)
-
PARENTS
12 MAIDEN NAME
OF MOTHER
adres Jewelry
18 BIRTHPLACE OF MOTHER (State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
te 12 Se
(Address)
16 Filed ., 191
REGISTRAR
16 DATE OF DEATH
17 I HEREBY CERTIFY that I attended deceased from Guy 10
that Last saw h .....
alive
Seft 29
1917.
and that death occurred, on the date stated above, at 8a
m. The CAUSE OF DEATH* was as follows :
Chrome Pulmonary
Rubriculares
Secree poration). ........... „yrs. ............... mos. ... .ds.
Contributory
(SECONDARY)
(Duration)
.yrs.
mos. ds.
......
M.D.
, 1919
...
. (Address)
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS),
At place
of death.
yrs.
... mos. ..
......
In the
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
Cef 6, 1917
20 UNDERTAKER
ADDRESS
(Month)
30
191.9
(Day)
(Year)
1917, to
Seft 30
191%
If LESS than I day ........ hrs.
10 NAME OF
FATHER
martini WallNew telung
11 BIRTHPLACE
OF FATHER
(State or country)
Breton
WRITE PLAINLT, WITH UNFADING INA - THIS IS A PERMANENT RECORD.
Withhot
-
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As cxamples: (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," 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 houseliold 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: 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 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- 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 ean be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized 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.
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 Winchip
( No 423 Withp
St. ........... Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Finale
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
vidro
OR DIVORCED
(Write the word)
6 DATE OF BIRTH 1850
(Month) (Day)
(Year)
7 AGE
If LESS than I day, ........ hrs.
... yrs.
mos.
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).
af hour
9 BIRTHPLACE
(State or country)
Canada
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Kuku
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Wouldn't mais
15
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
191
7
( Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
al Causes,
math Lardion
elar destare
oedema of the Lessgo yrs. ds.
mos.
Contributery (SECONDARY)
.mqs.
ds.
(Signed)
Burgers Dugul
M.D.
(Address)
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, 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).
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
1917
20 UNDERTAKER
ADDRESS
wacht
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
9168 winchup (City or town.
2 FULL NAME Ouna [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 42.3 mmultiop
Mª Rury.
Registered No.
1
10 NAME OF
FATHER
-
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is . necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Forcman," "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 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 (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 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., 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 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," "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. 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."
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 strect, or onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 16-8.'15. 5,000.
1
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1917.
CITY OF BOSTON
FULL NAME
J.WILSON PARKS
Registered No.
9740
Place of Death l
Boston
and Residence S
Date of Death
OCT.2
1917, Age 60
years
months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
W
Maiden Name
Husband's Name
GENERAL PARALYSIS OF INSANE
Birthplace
MASON VILLAGE.VT
Name of Father
JOHN PARKS
Birthplace of Father
ENGLAND
Contributory: (Duration )
--
Maiden Name of Mother
Birthplace of Mother
(Signed)
S.F .GORDON M. D.
OCT.2
1917
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT.7 MOS.
Place of Burial or removal
Undertaker
EVERETT (WOODLAWN)
C.R.BENNISON
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 :
RAR
Primary ( Duration
SOBIS.
6 YRS
CTVRT BOSTONIA
4 1822
CONDITAA
1850.
S
COMMINE DONATA A ON. MASS.
Occupation
PHYSICIAN(RETIRED)
Informant
Usual Residence
WINTHROP
OCT.5
Filed
1917.
A true copy. Attest : ErMSlenen
Registrar.
OFFICE
CITY
STATE HOSPT.
V SI
PLAINLY, WITH UNFADING INK -THIS
WRITE
Det. 2, 1917
3 SEX 7 AGE PARENTS important. See Instructions on back of certificate. (Address) 16 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
134 Han SL
(No.
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 134 Mani It Lumchurch man
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Marine
* DATE OF BIRTH
48 pro. 2
..........
mos.
20
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)
Plantucket Mars
10 NAME OF
FATHER
William Clicby
.
11 BIRTHPLACE
OF FATHER
(State or country)
Nantucket Mais
12 MAIDEN NAME
OF MOTHER
"Mary Crosby
13 BIRTHPLACE
OF MOTHER
(State or country)
Man tricket Man
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
William Clasby Son
Filed 191
...... REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
oct
(Month)
(Day)
191.7
(Year)
17 I HEREBY CERTIFY that I attended deceased from
191
act 42
1917
.........
to
that I last saw h Vm alive on
1917
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Gener.
arter sclerosis
.....
Chronic Interstitial Thewhite)
(Duration)
1 yrs.
........ ...........
mos.
ds.
Contributory (SECONDARY)
.. (Duration)
.............. yrs.
............... mos.
.........
ds.
(Signed)
M.D.
.... 1917 (Address).
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
.........
yrs.
mos. .......
In the
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
..
191
20 UNDERTAKER C.R.(Semana
ADDRESS
Registered No.
(Month) (Pay)
(Year)
1916
......
If LESS than day ..
.. yrs.
15.1939
(City or town.)
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 caclı 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 fircman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) 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," "Dcaler," 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 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 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 (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 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 causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., wlien 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 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 onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
OVANA HLIM
P SI SIHL - HNI ONIO
EN ERMAN
The Commmuuralin of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Wellesley
(No ....................... )
Grove
St. ;.................... .. Ward)
2 FULL NAME
Stephen W. Nickerson
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Boston, Maso.
WINTHROP
Registered No. 73
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
COLOR OR RACE
White
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
"Write the word)
Single
16 DATE OF DEATH
October 4, 1917
191
---
(Month)
(Day)
(Year)
" DATE OF BIRTH
1857 17
(Month)
(Day)
(Year)
7 AGE
60
yrs.
.. mos. ds.
Or ......... min. ?
& OCCUPATION
(a) Trade, profassion, or
particular kind of work ...
......
Lawyer
(b) General nature of Industry,
business, or establishment
which employed (or employer).
9 BIRTHPLACE
(State or country)
Boston, Mass.
Contributory. (SECONDARY)
(Duration)
yrs.
mos. .............
ds.
(Signed)
Edward H. Wiswall
M.D.
Oct. 4
7
191.
(Address).
Wellesley, Mass.
* 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.
In the
mos. ......
Where was disease contracted, If not at place of death ?
Former or usual residence
1 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Mt. Auburn (Cambridge) Oct. 6
197
(Address)
Boston Mass
16
Filed Oct. 13 1917 John J. Chiar
REGISTRAR
I HEREBY CERTIFY that I attended deceased from
Dec. 30
195
to
Oct. 4
1917
....
that I last saw him
alive on
Oct. 3.
1917
and that death occurred, on the date stated above, at
10 Pm.
m.
The CAUSE OF DEATH* was as follows : Locomotor Ataxia
Long DuratioDuration)
...... ... yrs. ............... mos. ................ .ds.
10 NAME OF
FATHER
Thomas W. Nickerson
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Boston, Mass.
12 MAIDEN NAME
OF MOTHER
Martha T. Wescott
13 BIRTHPLACE
OF MOTHER
Boston, Mass.
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Philip T. Nickerson
20 UNDERTAKER
E F WALLACE
ADDRESS
WELLESLEY
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
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.
Wellesley ----
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
If LESS than
1 day ......... hrs.
·Get. 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 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) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborcr," "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 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: Cerebro-spinal fever (the only definite synonym is "Epidemic cercbro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tubes
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," "Haemorrhage," "Inanition," "Marasmus,". "Old agc," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertaincd as the cause. Always qualify ali diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
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