USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 82
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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," unqualified, is indefinite) ; Tuber
culosis of tungs, meninges, peritonacum, etc., Carcinoma, Sur- coma, etc., of ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart discasc; 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," ctc., when a definite disease can be ascertained as the cause. Alway's qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS Statc. 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- posurc, 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, ete.
12 16. 7.16. 5,000.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country) Lincoln Le
12 MAIDEN NAME
OF MOTHER
Julia G Hardenberg
13 BIRTHPLACE
OF MOTHER
(State or country )
Jersey City N J
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
--
(Address)
16 Filed Dec 29 191
REGISTRAR
16 DATE OF DEATH
Dec 22 1917
191
(Month)
(Day)
( Year)
6 DATE OF BIRTH
March 1904
(Month)
(Day)
( Year)
7 AGE
If LESS than
day, .....
.. hrs.
13
yrs.
O
mos.
0
ds.
or ... min. ?
6 OCCUPATION
None
(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)
Cambridge
(Duration)
.......... yrs.
mos.
ds.
Contributory
Congenital mental defect
(SECONDARY)
(Duration )
yrs.
mos.
.ds.
(Signed)
Walter = Fernald
, M.D.
Dec 22
1917
(Address)
Waverley
* 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.
8
In the
13
State
.. yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or
usual residence ..
Winthrop
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
It Auburn Cambridge
20 UNDERTAKER
George A Clark
.ADDRESS
elcham
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 Veltham
(No .....
.......
St. :
Ward)
2 FULL NAME Lawrence ..... Reed ..... Tyman [If married or divorced woman or widow give maiden namc, also name of husband. ]. a RESIDENCE
(City or town.)
[If death occurred in hospital or institution, give its NAME instead of street and number.]
Winthrop
Registered No.
'++3
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( IFrite the word)
1
17
I HEREBY CERTIFY that I attended deceased from
Dec 14 1913
to
Dec 22 1911 91
that I last saw him.
alive on
Dec 22 1917
191
and that death occurred, on the date stated above,
20.45 m.
A
The CAUSE OF DEATH* was as follows :
Broncho pneumonia.
Chr valvular disease.
10 NAME OF
FATHER
Art' ur T.
1 Dec. 22, 1917
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to eacli 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 cngincer, Stationary fireman, ete. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm 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 oceupations 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 faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oceu- 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 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, cte., Carcinoma, Sar- coma, etc., of. . . . (name origin: "Caneer" 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 intereurrent) affection need not be stated unless im- portant. Example: Mcasles (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," ete.), "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, Suicide, Homicide, ete.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or onc supposed to be duc to Alcoholism, etc.
4. Deaths under eireumstances unknown, as A person found dead, etc.
R 1S. 10-'17. 10,000.
Y SI SIHL=XNI ANIQYING HUA
"PERMANEN
D3H_LN3
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 Winthrop (No. 262
May Luffiel
"FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Winthrop 262 Winthrop St
.... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
* SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
· DATE OF BIRTH
12
(Month)
4
(Day)
1917
(Year)
' AGE
If LESS than 1 day ......... hrs.
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)
gruethiop
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Covington y.
12 MAIDEN NAME
OF MOTHER
awiec. Higgott
13 BIRTHPLACE OF MOTHER (State or country Youngaoun Ohio
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
ChaoH Luffreid
(Address)
26 2 withus &t
16 Filed 191
REGISTRAR
1ª DATE OF DEATH
12 24.197 ....
(Month)
(Day)'
(Year)
17 I HEREBY CERTIFY that I attended deceased from 22. 47917, 191 ..... ......... to 191 that I last saw her alive on 191 and that death occurred, on the date stated above, at m The CAUSE OF DEATH* was as follows :
......
.. (Duration)
................ yrs. ................ mos. ds.
Contributory.
(SECONDARY)
.. (Duration)
.............. yrs.
..............
. mos.
ds
(Signed)
0
2/20
1917 (Address) 35
* 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
.mos.
„ds ...
Where was dlsease contracted, If not at place of death ?...
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Winthrop Cut 12-27
1917
20 UNDERTAKER
W.C. Skaggs
ADDRESS
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
1
St .;
......... Ward)
.......... .........
At place
of death ...
yrs. ............ mos.
. .............
.ds.
State ...
........ yrs,
.......
M D
....
10 NAME OF
FATHER
Leiffreid Chas. A.
.. yrs. ... mos. ...... 21 ds .
9HOOTHANANYAH3d Y SI SIHL-XNLANIQYAND HUMANIYd.3UHM
J Ilec . 24, 1917
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- ipation 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 enginecr, 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 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 laborcr, 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 employcd, 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 (rctired, 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 discasc. 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 indefinitc) ; 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 (sccondary), 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, 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, ctc.
HIN NA ILIMANGNI NEUUNU.
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.
[5-'17-XXM.} The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop .. (No .... 355 Minut
Margaret Josef he's
Fondergast Maloney
Widowof Thomas maloney @RESIDENCE 305 Winthropesto
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
' COLOR OR RACE
Female White,
§ SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
Widow
· DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
If LESS than
( day ......... hrs.
yrs.
ds.
.....
min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
At Home
Home
(b) General nature of Industry. business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
East Boston
Doslow
10 NAME OF
FATHER
Nicholas Tendregast
PARENTS
LI BIRTHPLACE OF FATHER (State or country Sécland
JE MAIDEN NAME OF MOTHER march nº Cafferty
13 BIRTHPLACE OF MOTHER (State or country)
Yvelandy
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Luo gary Fulham
(Address)
350 Manwhich It
16 Flled
191 11
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
...
(Month)
27, 1917
(Day)
(Year,
17 I HEREBY CERTIFY that I attended deceased trom
....
1917 t
191
7
that I. last saw her alive o
191
and that death occurred, on the date stated above, at ....
.......
... m.
The CAUSE OF DEATH* was as follows :
Carcinoma"
-
Did a surgical operation precede death ?
Date
.(Duration)
........ yrs.
.mos. ............. ds.
Contributory (SECONDARY)
(Duration)
.yrs. ................ mos.
ds.
............
(Signed)
M.D.
04:12. 1917 (Address): 250
........
..........
ex
* 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. .......
In the
Where was disease contracted, If not at place of death ?. Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Holy leves malden
DATE OF BURIAL
DEc.39, 1917
20 UNDERTAKER
.
Winthrop BOSTON .....
St. ;...
............ Ward)
(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 of widow give maiden name, also Name of husband.] ...
.......
ADDRESS
Winthrop
...
mos.
a
+ Dec. 27, 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 agc. 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 nccded. 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, ctc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who reccive 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 tho 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 indefinite) ; Tuber .
culosis of lungs, meninges, peritonaeum, etc., Careinoma, Sar- coma, etc., of .... ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie valvular heart discase; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection necd not bo 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Hcart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Wcakness," etc., when a definite discase can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deatlıs supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized discase, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15. 1-'17. 100,000.
ILIM WRITE PLAINLY.
ONICYANO
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.
PARENTS
13 BIRTHPLACE
OF FATHER
(State or country)
Olucago All
12 MAIDEN NAME
OF MOTHER
Mini Click
13 BIRTHPLACE
OF MOTHER
(State or conntry)
Marchar Mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
annie Tellers
(Address)
117 thore Que
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
(Month)
28.1917
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
to
Oct. 15.
1917
Acc. 28.
19171
...
that I last saw hele alive on
Dee. 29,
1917.
and that death occurred, on the date stated above, at
... m
The CAUSE OF DEATH* was as follows :
ulmonary Tuberouler
Did a surgical operation precede death ?
Date
Several years
.(Duration)
.......
yrs.
............... mos.
...............
.ds.
Contributory ..
(SECONDARY)
(Duration)
.yrs.
mos.
...... ds.
(Signed)
Dec. 28.
191 ...... (Address)
....
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death ............ yrs.
mos. ..........
ds.
State ............ yrs.
.. mos.
........... ds ...
Where was disease contracted, if not at place of death ?..
Former or usual residence.
18 PLACE OF BURIAL OR REMOVAL Belmont
Gemacht
DATE OF BURIAL
Dec 30
1917
mars
Winthrop BOSTON ......
(City or town.)
[if death occurred In a hospita or institution, give its NAME instead of street and number.J
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 117 Shore Drive Winthrop
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Malé
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
July 16 1873
(Month)
(Day)
1
(Year)
PAGE
44
5
12
ds.
.. yrs.
mos.
if LESS than
1 day ......... hrs.
or ...
„min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Newspaper
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Belmont Mass
10 NAME OF
FATHER
Laggie Brainard
[5-'17-XXM.] The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop ......
(No. 117 Shore Drive St. : Ward) .....
Chester n. Brainard.
....
Registered No.
20 UNDERTAKER
U. H. Graham
ADDRESS
Boston
M.D
Dec. 28, 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, Architcet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Forcman, (b) Automobile factory. The material worked on may forni part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," cte., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal minc, etc. Women at home, who are engaged in the duties of the household only (not paid 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, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATII, 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 eccu- pation whatever, write None.
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