USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 83
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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 discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie ecrebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- 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 (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," "Heart failure," "Hacmorrhage," "Inanition," ? "Marasmus," "Old age,". "Shock," "Uracmia," "Weakness," etc., when a definite disease can be ascertained 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. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized discasc, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15. 1-'17. 100,000 .;
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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
F
St. :
Ward)
Canvere (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
Female
4 COLOR OR RACE
white
5 SINGLE,
MARRIED, Widowed
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
day. ....... hrs.
68 .. yrs. ....... mos .... ds.
or _..... min .?
B 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)
Mase.
PARENTS
12 MAIDEN NAME
OF MOTHER
Maryli, Hathaway
13 BIRTHPLACE
OF MOTHER
(State or country)
mars.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Justis Toch
(Address)
Hawthorne Maso.
15 ANC ., 1917 Julius Prale
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
December 28
(Month)
(Day)
191
(Year)
17 HEREBY CERTIFY that Lattended deceased from to 7.8. 1 Dec. 28, 1917.
that I last saw her alive on.
Dec.
28
197 and that death occurred, on the date stated above, at 8:05 m. a.m. The CAUSE OF DEATH* was as follows : arteriosclerosis
(Duration)
.......
.yrs.
mos. ds.
Contributory
(SECONDARY)
(Duration)
.yrs.
mos. ds.
(Signed).
W.A. Bryan
, M.D.
Jan. 6. 1918 (Address).
Danvero State Hargita
* 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
1
mo8.
20 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
Wareham Cemetary
Marcham, Maso.
DATE OF BURIAL
Dec. 30, 197
ADDRESS
Northrop
20 UNDERTAKER W. C. I Dag 9
mano
MARGIN RESERVED FOR BINDING
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH d'anvers,- Stale No Hospital Maryt Filleon 2 FULL NAME [ If married or divorced woman or widow give maiden name, also name of husband. ]. RESIDENCE Winthrope
7
10 NAME OF
FATHER
Games M. Fuller
11 BIRTHPLACE
OF FATHER
(State or country)
Fraina
Mary & Silvaon
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 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) Groccry; (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 minc, 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 lias 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 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 eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL 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. Deathis 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, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R 18. 10-'17. 10,000.
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
(No. 262, Hrucheops
St. : Ward)
(City or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
* SEX
H
4 COLOR OR RACE
w
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
" DATE OF BIRTH
12 (Month)
(Day)
' AGE
If LESS than
[ day ......... hrs.
mos. 28 de
..............
...... .....
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)
9 BIRTHPLACE
(State or country)
Winthrop
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Covington Ky.
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Char H. Luffered
(Address)
267 Wintheof St
16 Filed ., 191 .....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
12
(Month)
(Day) 28 191.> (Year)
17
I HEREBY CERTIFY that I attended deceased from
Len. 4
191 ), to
X
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 :
.(Duration)
... yrs.
...........
............... mos. ................ ds.
Contributory
(SECONDARY)
.... (Duration) .. yrs. ...... .............. mos.
.............. ds
.n
M.D
29
......
191 ....... (Address).
850
* 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.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Withcon Cat 12-31, 192
O UNDERTAKER
W.C. Skaggs
ADDRESS
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See Instructions on back of certificate.
any Leibfeed
*FULL NAME
[If married or divorced woman of widow give maiden name, also name of husband.] RESIDENCE 262 Winthrop St. Wintherto
....
Registered No.
4 .. 1917 (Year)
10 NAME OF
FATHER
chas. H. Leiffreid
..............
(Signed)
......
....... .
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 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 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 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 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, 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 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 strect, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dcad, etc.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate. N. B. - Every Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH In plain terms, so that It may be properly classified. Exact statement of OCCUPATION is very
[5-'17-XXM ] The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH Winthrop- Mass (No. 450 Pleasant St. ;.... .............. Ward)
Winthrop - Mass
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
'FULL NAME Giovanna Marotta
[If married or divorced woman or widow Giovanna Materazzo wife of Raffaele Marotta give r @RESIDENCE
450 Pleasant St, Winthe Mass?
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1 SEX
Female White
4 COLOR OR RACE
$-SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed"
# DATE OF BIRTH
unknown
(Month)
(Day)
1
(Year)
1 AGE
85
........... mos. ds
or
min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
At Home
(b) General nature of Industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
Italy
10 NAME OF
FATHER
Antonio Materazzo
11 BIRTHPLACE
OF FATHER
(State or country)
Italy
12 MAIDEN NAME
OF MOTHER
Agnesa Cataldo
13 BIRTHPLACE
OF MOTHER
(State or country)
Italy
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Francesco Marotta
(Addres
450 plesant A, Winthrop
16
Filed
191
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
De12.28
191
191
... ......
that I last saw her alive on
191
....
and that death occurred, on the date stated above, at
,
96.
The CAUSE OF DEATH* was as follows :
interio - silenzio ins cardiés
Did a surgical operation precede death? 2., Date
.(Duration)
.............. yrs.
...........
... mos.
............ ds.
Contributory. ......
(SECONDARY)
(Duration)
......
.. yrs.
.............. mos.
............
ds.
(Signed)
1
1918
....
(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.
ds.
State ............ yrs.
mos.
...... ds ............. Where was disease contracted, If not at place of death ?....... Former or
usual residence.
450 Pleasant St. Winthrop-wall
.....
19 PLACE OF BURIAL OR REMOVAL Holy Cross Cemetery
DATE OF BURIAL
Jan, 22 1918
20 UNDERTAKER
Cangiano + Jamini
ADDRESS
215 WorthSt
18 DATE OF DEATH
Sec, 29th
(Month)
(Day)
197 (Year)
If LESS than
I day ......... hrs.
..................
PARENTS
In the
M.D
Dec. 29, 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, 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 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 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 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 "Epidemie ecrebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumenia ("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- aemia" (merely symptomatic), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "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 deathis of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15. 1-'17 *100,000.
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
(No.
89
.... .............. Ward)
'FULL NAME
Israel R. Housigle
...
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
89 Seminet Que. wetheufo
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1 SEX
4 COLOR OR RACE
5 SINGLE.
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Mamed
187/ 17 (Year)
' AGE
If LESS than
i day ......... hrs.
.. min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work .....
Igs. cily
(b) Generel nature of industry, business, or establishment in which employed (or employer).
º BIRTHPLACE
(State or country)
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Freeport Mr.
C
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
2. FR. Woodside
(Address)
89 Semainet Cor
16
Filed 191
REGISTRAR
1ª DATE OF DEATH
1
(Month)
(Day)
1918
(Year)
1 HEREBY CERTIFY that I attended deceased from
(Och 1 0/
1916 to.
Law. A.
1918-
that I last saw have a live on fraw. 4.
1918.
and that death occurred, on the date stated above, at
....
1.00
m
The CAUSE OF DEATH* was as follows :
Pulmonary Veberculosis
...
(Duration)
.yrs.
......
mos.
ds.
Contributory
Hemorrhage (Jungs)
(SECONDARY)
.(Duration)
.yrs.
mos.
ds
(Signed)
fem. 6.
1915 (Address)
Wenietraf
* 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 ............ yr8. ............ mos. ............ ds ....
............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OB REMOVAL
Dortlared
Everque lunch
DATE OF BURIAL
Tomate.
191
20 UNDERTAKER
N.C. Skaggs
ADDRESS
Winthrop
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
· DATE OF BIRTH
9
(Month)
19
(Day)
46 yrs.
3
mos.
15 50
10 NAME OF
FATHER
Samuel Wordende
............
......
....
M.D
PERMANENT SI SIHL - XNI ONIOVE
VINO H.LIM ATI WRITE PLAINLY
Jan . 4, 1918
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Frecise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupation 3 a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil 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 cxamples: (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 "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- 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 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.
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