USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 81
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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- 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," "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 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.
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.
109 Quaient Rd
St. :
2
Ward)
Catherine
Cecelia Hosta
[If married or divorced woman or widow give maiden name, also name of husband.j @RESIDENCE West, Lebanon M.H.
Widow Oscar, Edwin Foote
....
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
geral
4 COLOR OR RACE
1. Muito
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widows
· DATE OF BIRTH
lech
1844.
1
(Month)
(Day)
(Year)
7 AGE
73 2
10
ds.
or min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
cet Homme
(b) General nature of industry, business, or establishment In which employed (or employer)
9 BIRTHPLACE
(State or country)
Prince Edward Island
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Sarah Duffey
18 BIRTHPLACE
OF MOTHER
(State or country)
Freland
N THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Ce 12 Bemvin
(Address)
16
Filed 191
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
191.
, to
191
........
that 1 last saw h ...
alive on
191
......
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
arcinonno ! 22te 1 ...
(Duration)
....... yrs.
.......
mos.
ds.
Contributory.
(SECONDARY)
(Duration)
.. yrs. ................ mos.
ds.
(Signed)
M.D.
(Www. ) . 191) (Adres).
3.10
.....
* 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 ............ y:s.
mos.
......
Where was disease contracted, If not at place of death 7.
Former or usual residence
DATE OF BURIAL
19 PLACE OF BURIAL OR REMOVAL Hargjort Cumuli Nest LebanonIN, 12/19
......
1917
20 UNDERTAKER Celso R. Benman.
ADDRESS Winthings
.... .
., 191 ..
(Day)
(Year)
16 DATE OF DEATH
Duv
(Month)
17
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
* FULL NAME
10 NAME OF
FATHER
Patrick Clark
If LESS than
[ day ......... hrs ..
.... yrs. mos.
SISIHL
20cc 17,1917
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, c. g., Farmer or Planter, Physician, Compositor, Architect, Loeo- motive cngincer, 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 inaterial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housc- 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, Houscmaid, 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 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," 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" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemnia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieacmia," "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.
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.
[10-'16-XXM.] The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
WINTHROP (No. 32 EDGEHILL ROAD St. : ..... .. Ward)
' FULL NAME
STIMMER EDWARD YOUNG
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 32 FDGEHILL ROAD
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
& SINGLE,
MARRIED
WIDOWED,
OR DIVORCED INGLE
(Write the word)
1
(Month) (Day)
(Year)
If LESS than
1 day ........ hrs.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
STUDENT
(b) General nature of industry, business, or establishment which employed (or employer)
9 BIRTHPLACE
(State or country)
WINTHROP
MASS.
10 NAME OF
FATHER
TILTY S YOUNG
11 BIRTHPLACE
OF FATHER
(State or country}
SHELBOUTI I.S.
12 MAIDEN NAME
OF MOTHER
LULU M. FLOYD
12 BIRTHPLACE
OF MOTHER
(State or country)
MASC.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)
3ª EDGEHILL ROAD
.... .............
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
leander
19
(Month)
(Day)
197
(Year.
17
I HEREBY CERTIFY that I attended deceased trom
200 30
191.2., to
Que 19
1919
that I last saw he
alive on
19
1917
and that death occurred, on the date stated above, at 1100m
The CAUSE OF DEATH* was as follows :
Ciente ascending Spmal
Paralysis (Landis paralysis)
Did a surgical operation precede death
no
Date
.(Duration)
yrs.
mos.
5 da
Contributory.
Brandon primaria
(SECONDARY)
.(Duration)
.......
.. yrs. .............
„ds
(Signed)
Carrete Efocuson
M.D.
20. 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
... yrs.
......
... mos.
ds
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
VINTEROP CT
MI
DATE OF BURIAL
A2022, 1917
ADDRESS
20 UNDERTAKER
Frederick Bugge vostri
WINTHROP -BOSTON- ...
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
3 SEX
CALE
' AGE
PARENTS
(Informant)
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
T 4
16 Filed
191
........
..............
...
......
· DATE OF BIRTH
ADPTIT, 24 7903
yro. ...... mos. . 5 ds.
H IN
PERMANENT HNL_DNIGYANA HUMAINIYI_ WRITE P
ʻ Dec. 19,1917
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 applics 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 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," "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- kcepers 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 (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 discase. 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, 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 nced 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 agc," "Shock," "Uraemia," "Weakness," etc., when a definite discasc 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 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
Winthrop
(No. 174
Munching
St. ;.... ............. Ward)
......
to
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
20, 1917
....
(Month)
(Day)
(Year)
' DATE OF BIRTH
7
(Month)
29
(Day)
PAGE
47 .yrs. 57, 140 .... ds.
...... ........... mos.
& 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)
St. Johns. 91.13.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Cambridge n. B.
12 MAIDEN NAME
OF MOTHER
Afarmach Vaughan
13 BIRTHPLACE
OF MOTHER
(State or country)
St. Johns n/3.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Horton Chanchulai
(Address) H1 Chester leur
15
Filed
191
....
REGISTRAR
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Edith V. Wellington
"FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] aRESIDENCE 23 Ocean car. Huthiop
$ SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
.....
1870
17
I HEREBY CERTIFY that I attended deceased from
(Year)
U 15
191.2 .... , to
Dec20
191.7_
If LESS than
1 day ......... hrs.
that I last saw her alive on
Ouro
1917
or ........ min. ?
and that death occurred, on the date stated above, at 6pm
The CAUSE OF DEATH* was as follows :
......
Indefinite
(Duration)
........... yrs.
.........
... mos. .............
.ds.
Contributory
(SECONDARY)
(Duration)
.......
yrs.
...........
mos.
6
ds
(Signed)
M.D
1917 (Address).
218 mais hi Viel
* 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.
7
ds.
State .......
mos.
ds.
.yrs.
Where was disease contracted,
If not at place of death ?.
Former or
23 Genau an Wattuy Mans
usual residence.
.........
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Winthrop Quent 12-23.
......
191
20 UNDERTAKER
N.C. Skaggs
ADDRESS
Winthrop
.INN AT LATANLNI NEVUNU.
10 NAME OF
FATHER
Samuel G. Golding
Golding! Hran Nellie
N. B
Dec. 20,1917
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Freeise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to each .and every person, irrespective of age. For many 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 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 needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, 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 Servant, Cook, Housemaid, etc. If the oceupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. -· Name, first, the DIS- 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 eerebro-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, peritonacum, ete., Carcinoma, Sar- coma, etc., of ..... (name origin: "Caneer" 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 symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., when a definite disease ean be ascertained as the eause. 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, etc.
2. Deaths supposedly eaused by violenee, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ete.
4. Deaths under eireumstances unknown, as A person found dead, etc.
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
PARENTS
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)
16 Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
22
(Month)
(Day)
191.2 (Year)
6 DATE OF BIRTH
ale 15-1851
(Month)
(Day)
(Year)
7 AGE
If LESS than [ day, . hrs. The CAUSE OF DEATH* was as follows :
.. yrs. mos.
ds.
or
min. ?
$ OCCUPATION (a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
(Duration)
.. yrs.
mos. ds.
Contributory (SECONDARY)
(Duration) . . . .. yrs.
... mos. ds.
(Signed) ...
12,1
(Address).
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATHI, 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 placo
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
Winthers 12/2617 Winetwoh - 1919.
:0 UNDERTAKER
GR. Benim
ADDRESS
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME augustine
Poggi
[If married or divorced woman or widow give maiden name, also name of usband.] @RESIDENCE 0 Pleasant Park ave Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
· OR DIVORCED
(Write the word)
Widower
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH 1 Winthrop
(No. 50 Pleasant Park alos Ward)
9347 Winthrop (City or town
DATE OF BURIAL
Punitan
M.D.
9 BIRTHPLACE
(State or country)
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (State or country)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
NICVANA
WRITE PLAINLY, WITH
c 1 STANDARD CERTIFICATE OF DEATH. 1
Statement of occupation. - Frccisc 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 cxamples: (a) Spinner, (8) 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 Nonc. r
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