USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 76
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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 "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- 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) ; Mcasles; 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," "Wcakness," 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, 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 strcet, 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.
VI ONIOVANA HIIM "
RM SI SIHL->
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
36 Llenges the IN Merchant Mar .
addison A. Gulick
-...
(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.]
@RESIDENCE
36 Hlingis St Wuchsof Man
Registered No. ...
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Mute
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Manès
Left 2.3
(Day)
(Year)
Och
15.
191
Och. 24.
1911-
..
7, to
that I last saw h lew alive on
Oct. 22.
.. 1917.
........
and that death occurred, on the date stated above, at
....... m. The CAUSE OF DEATH* was as follows :
arteriosclerosis
Index.
(Duration)
............. yrs.
mos. ................ ds.
Contributory ..
(SECONDARY)
........... (Duration)
.............. yrs.
.............
.mos.
ds.
(Signed)
M.D.
(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. ..........
ds .............
Where was disease contracted, If not at place of death ?. Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Worcester Man
DATE OF BURIAL
Qef-27
7
191
16 Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Oct.
(Month) 24 191. 7 (Year)
(Dáy)
7 AGE 44
If LESS than
1 day ......... hrs.
X mos. X ds. or ........ min. ?
... yrs.
Returet
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer).
Dy Goods
9 BIRTHPLACE
(State or country)
Princeton- n.J.
10 NAME OF
FATHER
Ralph. Gulick
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Suncelow- M.J.
12 MAIDEN NAME
OF MOTHER
Eleza. Burgeri
18 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
OR Quam
(Address)
20 UNDERTAKER
CR. Pensa
ADDRESS ,
Wellant
Ward)
· DATE OF BIRTH
1843
(Month)
17 I HEREBY CERTIFY that I attended deceased from
A
SIML -YNI ONICYJNA HLIM
XINIVId 3LIMM
Let. 24,1917
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 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, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when uceded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in 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 110 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 discasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-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, 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 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," "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 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.
1917 74 3
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
Cambridge
Copp Hosp.
(No .... 10.Chester
St. :
Ward)
- -Norwood
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
41 Pearl Ave., Winthrop
Registered No.
1615
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
tober ... 2.4th .......
1.91.7 ........... , 191
(Day)
(Month)
(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 :
Still born
......
(Duration)
yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration)
.. yrs.
.........
mos.
ds
(Signed)
T ............. Br3.88.11
M.D.
Oct.26 17
(Address)
Cambridge
* 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 7.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
camb.Cem.Camb.
oct. 24
197
ADDRESS
Filed Oct.2919 .... 7€
12
edou
REGISTRAR
Cambridge
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
3 SEX
M
6 DATE OF BIRTH
7 AGE
& OCCUPATION
(a) Trede, profession, or
particuler kind of work
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
12 MAIDEN NAME
OF MOTHER
PARENTS
WITTE PLANET, WITT OffFADING INK InIS 19 A PERMANENT RECORD.
(b) General nature of industry,
business, or establishment
which employed (or employer).
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
S
(Month)
(Day)
1
(Year)
If LESS than
day ..
0
mos.
ds. or ....... min. ?
Cambridge , Mass.
Ralph
11 BIRTHPLACE
OF FATHER
(State or country)
Maine
Lottie Donnelly
13 BIRTHPLACE
OF MOTHER
(State or country)
Boston , Mass.
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Ralph Norwood,
(Address)
Father-
........
20 UNDERTAKER
Jos. H. Ricker , Cambridge
Oct. 24, 1917
CHOD3) INJNYWy3J V SI SIHL -XNI ONIOVINA H.LIM
'AINIVT .. .. NM
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 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 iy 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) 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 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 terin for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Careinoma, Sar- coma, etc., of .... ............ (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; Mcasles; 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- acınia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasınus," "Old age," "Shock," "Uracmia," "Weakness," cte., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as Å person found dead, etc.
N. B .- Every Item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop .(No ... 181 Pleasant St. : ........... Ward) . ....
Winthrop
(City or town
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
NAME
[If married or divorced woman or widow give maiden name, also name of husband.] ...
Kiene - Andrew, Hall
@RESIDENCE
181 Pleasant Er Withurk
.... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
Female White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
· DATE OF BIRTH
aug
(Month)
(Day)
1832 27
(Year)
7 AGE
85
... yrs.
2
mos.
18
ds.
Or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
It Home
(b) General nature of Industry, business, or establishment In which employed (or employer).
9 BIRTHPLACE
(State or country)
Montville. De
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country).
Vontville De
12 MAIDEN NAME
OF MOTHER
Mercy Sinimons
1ª BIRTHPLACE
OF MOTHER
(State or country)
Damariscotta de
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Nie Hired Healing
(Address)
16
Filed
191
REGISTRAR
(Duration)
... yrs.
mos.
.ds.
7
Contributory
(SECONDARY)
.(Duration) .yrs.
mos. ... ds.
(Signed)
M.D. Cual 28, 1917 (Address) .....
200 Pleasant 81
* 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 usual residence.
19 PLACE OF BURIAL OR REMOVAL
181 Pleasant Rst Wanthus Rockland Me
DATE OF BURIAL
Wer 29.
7
191.
20 UNDERTAKER E. G. Brown Kom
ADDRESS
East Boston
(Day)
28, 1917
(Year)
I HEREBY CERTIFY that I attended deceased from
er 25, 1919, to
Mar 28, 1917.
that I last saw he alive on
6 cv 27, 197
and that death occurred, on the date stated above, at
6/7m.
The CAUSE OF DEATH# was as follows :
1
10 NAME OF
FATHER
Ephram Keene
.... If LESS than i day ......... hrs.
16 DATE OF DEATH
eck
(Month)
10
Forica D).
Hall
Fect 28, 1917
LNANYWH3d V SI SIHL -HNI ONIOYING HLM 'AINIVT ..
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 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 nceded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobilc 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, 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 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. - Name, first, the DIS- BASE 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- pneumonia ("Pneumonia," unqualificd, is indefinitc) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. ... (name origin: "Cancer" is Icss definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (sccond- 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," "Scnile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL scpticaemia," "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.
important. See Instructions on back of certificate. N. B .- Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No. 108 Bay Guru avx
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
....... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
Muito
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word married
manica
" DATE OF BIRTH
aluguer - 30 -
(Month)
(Day)
(Year)
7 AGE
...... If LESS than [ day ........ hrs.
38 Yra.
......
2
„ ... mos.
.ds.
Or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Inacliquic.
(b) General nature of Industry,
business, or establishment in
which employed (or employer).
automobiles
9 BIRTHPLACE
(State or country)
Ty) Glauque Scotland
10 NAME OF
FATHER
Monzael
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE OF MOTHER (State or conntry)
Scotland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mus. Cranston
(Address)
108 War Gren QUE
16 Filed 191
....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Oct
30
(Month)
(Day)
1917
(Year)
1
I HEREBY CERTIFY that I attended deceased from
1912
to
......
Gt30
1912
-
that I last saw him alive on
oct 29'
1917.
and that death occurred, on the date stated above, a
830Am.
The CAUSE OF DEATH# was as follows :
Chronic Endocarditis
Insufficiency mitral valve
(Duration)
1 yrs.
mos.
.........
ds.
Contributory
(SECONDARY)
(Duration)
./ ........... yrs,
.mos.
.........
ds.
(Signed)
(31 mil call
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
In the
of death.
....... yrs.
.mos. ............. ds.
State ............ yr8. ............
.. 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 Chas Q. Banuein Phinthish
.
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 108 Bay Thewave
? FULL NAME
Thom homas
Wilson Cranston
1899
17
30,1917
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 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 may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the 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 oceu- pation whatever, write Nonc.
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