USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 89
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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. Deatlıs 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
[5-'17-XXM.]
The Commonwealth of filassarhusetts STANDARD CERTIFICATE OF DEATH
6 __ -
BOSTON ..........
(City or town.) [If death occurred In a hospita or institution, give its NAME instead of street and number.]
? FULL NAME susan A.Macgowan
[If married or divorced woman or widow Susan A.Hall widow of Peter S.
give maiden name, also name of husband.1 @RESIDENCE
491 Pleasant Street winthrop. Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1 SEX
female
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
widowed
6 DATE OF BIRTH
Oct 11 1847.
(Month)
(Day)
(Year)
7 AGE
70
F
... yrs.
mos.
ds.
or
„min. ?
& OCCUPATION (a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment which employed (or employer)
9 BIRTHPLACE
(State or country) Chelsea Mass.
IC NAME OF FATHER Isaac Hall.
PARENTS
LI BIRTHPLACE OF FATHER (State or country) Sandwich Mass.
12 MAIDEN NAME
OF MOTHER
Susan Ryder.
11 BIRTHPLACE
OF MOTHER
(State or country)
Chatham Mass.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Mrs. Early
(Informant)
(Address)
491 Pleasant Street
16
Filed 19!
REGISTRAR? 1
17
I HEREBY CERTIFY that I attended deceased from
law. 15
,
1918, to
Freb. 10.
1918.
that I last saw her alive on
Feb. 10.
1918
and that death occurred, on the date stated above, at.
.m.
The CAUSE OF DEATH* was as follows :
Organic heart disease
Did a surgical operation precede death ?
Date
Indefinito
(Duration)
.yrs.
Contributory.
Bardine & Penal Droppay
(SLCONDARY)
6
(Duration)
.. yrs.
mos. ds.
M.D.
(Signed)
Fich. 12
191
(Address)
Winthrop
* 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 cr usual residence
19 PLACE OF BURIAL OR REMOVAL winthrop Cem'
DATE OF BURIAL
Hub.14, 1918
20 UNDERTAKER Slatermantsans
ADDRESS Postan
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
1 PLACE OF DEATH Winthrop
(No. 491 Pleasant Street St. ....... Ward)
16 DATE OF DEATH
February
16. 198
(Day)
(Month
( Year)
1
If LESS than
I day.bis
mos. ...........
dı.
In the
Feb . 10 , 1918
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 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 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- CASE CAUSING DEATHI (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 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, peritonacum, etc., Carcinoma, Sar- coma, ete., of .. .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Meastes (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mero 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 disease can be ascertained as the eause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- A
PERAL septicacmia," "PUERPERAL peritonitis," ctc. State eause for which surgical operation was undertaken.
Cases for the Medical Examiners. -- Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized 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.
anddne AlingaJuo
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
AdoA
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
14
Informant
Emma. G. Shoulding
(Address)
15
Filed 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Feb .10 19 | 8
17 I HEREBY CERTIFY, That I attended deceased from
Jan. 19
៛
1962
to
19
.
that I last saw holen alive on
Feb. 10.
19
18.
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
If LESS than
I day, ........ hrs.
or ........ min.
Cerbral Hemorrhage
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Geoeral oature of iodustry, business, or establishment io which employed (or employer) (c) Name of employer
9 BIRTHPLACE (eity or town)
Lowelle
(State or country)
10 NAME OF FATHER Ecorge, Fisk Shanddary
11 BIRTHPLACE OF FATHER (city or town) Hardwick (State or country) Vermont-
12 MAIDEN NAME OF MOTHER Joanna Small
13 BIRTHPLACE OF MOTHER (city or town) (State or country) Gullón Bay
71.4
* State the DISEASE CAUSING DEATII, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR-REMOVAL
Oak Grove West Dreadful
DATE OF BURIAL
2/14
1918
20 UNDERTAKER
ADDRESS
or
City
No.
,
or Village.
140 Chiff aven
St ..
. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
tcharles. Her son Shoulding
(a) Residence.
No.
140 Cloff
Cuz . ...
St.,
Ward.
(Usual place of abode)
Leogth of residence in city or towo where death occurred
w
years
2
mooths
days.
How long io U. S., if of foreign birth ?
68
years
10
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Make
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Emma. S.
1
G DATE OF BIRTH (month, day, and year) april 4-1 8.+1.
7 AGE 68 Years
Months
10
Days
(duration)
.yrs ...
mos.
ds.
CONTRIBUTORY
.(duration)
yrs ..
.... . ..... mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
200.
Date of -
Was there an autopsy ?
red
What test confirmed diagnosis ?
Sphygmo manon.
(Signed)
... , H.D.
4/2: 19/8 (Address)
PARENTS
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATHO
County
Suffolk
Township
Winchiof
.. State
Mars
Registered No.
(If non-resident give eity or town and State)
RECORD. PERMANENT
N. B .- WRITE PLAINLY, WITH UNFADING INK -THIS IS A
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Preeise statement of occupa- tion 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, Compos- itor, Architcet, Locomotive 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial 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 Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Naine, first, the DISEASE CAUSING DEATII (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, 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 (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere syınp- toms or terminal conditions, such as "Asthenia." "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Comna," "Convulsions," "" "Debility" ("Con-
genital," "Senile," etc.),
"Dropsy,"
"Exhaustion,"
"Heart failure," "Hemorrhage,' re." "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease ean be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to de- termine 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 (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Casas for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following 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, 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.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
14
Informant Mr. Checkerifigenia
(Address) 69 fremont stunulled
15
Filed
., 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Feb. 11. 1918
17 HEREBY CERTIFY, That I attended deceased from
Fich , 1914 to. 19 8.
that I last saw h.
alive on
fich. ro.
,19
and that death occurred, on the date stated above, at za, m. The CAUSE OF DEATH* was as follows :
Dendetente
(duration)
yrs ................. mos.
ds.
CONTRIBUTORY
aceite. Infabrité
(SECONDARY)
(duration) yrs ... / ... mos .. ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?. $20. Date of-
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
2/2, 19/8 (Address) Winthrop .
M.D.
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
2-13
19/8
ADDRESS
20 UNDERTAKER
M.C. Skaggs
(City or town)
1 PLACE OF DEATH
County
Suffolk
Township
or Village.
or
St .. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
May EmmaXent
(a) Residence.
No ...
69 Avmont
St., Ward.
(If non-resident give city or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
W
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowch
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7-24-1846
7 AGE
Years
Months
6
Days
18
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work ..
Housewife
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Huport
(State or country) n.S.
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
Freeport
(State or country) n=8.
12 MAIDEN NAME OF MOTHER
Mary Crocker
13 BIRTHPLACE OF MOTHER (city & town) Theepal (State or country) n.90
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
State mark.
Registered No
City
gutha
No.
(Usual place of abode) Leogtb of resideoce io city or town wbere death occurred 20 years moothis - days. How long in U. S., if of foreign birth ? years
71-
.
AJUA
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupa- tion 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, Compos- itor, Architect, Locomotive 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial 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 Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At homc. Care should be taken to report spe- cifically 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Naine, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- ficd, is indefinitc); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, 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 (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terininal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"""Debility" ("Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus,' s," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all discases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine 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 (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Casas for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following 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, 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.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
thou
AGE ahd WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
7 AGE - PARENTS 14 of certificate. 15 N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, -
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Winthrop (City or town
1 PLACE OF DEATH
County.
Jukfoller
Township
City
No.
or Village.
metcalf Heelital.
St ...
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
William Edwin Kell
(a) Residence.
15 Dolfilin are
St.,
Ward.
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
28 days.
How long in U. S., if of foreigo birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male Mute
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Vingle
5a If married, widowed, or divorced
HUSBAND of
(01) WIFE of
6 DATE OF BIRTH (month, day, and year)
Jan 141918
1
Days
28
If LESS than I day, ........ brs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work
(b) General nature of indostry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Mathrole.
(State or country)
mars
10 NAME OF FATHER martin
11 BIRTHPLACE OF FATHER (eity or town).
(State or country)
marie.
12 MAIDEN NAME OF MOTHER
Ruth Smith.
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
Informant
Omany R. Bell
(Address)
Filed 4. 19.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Feb. 12
19 18
17 I HEREBY CERTIFY, That I attended deceased from
1918, to.
76-12
1918
that I last saw him
... alive on
, 1920
and that death occurred, on the date stated above, at 4 j-m.
The CAUSE OF DEATH* was as follows : Premature.
manitin
(duration)
.. yrs ..
1
mos.
ds.
CONTRIBUTORY
Convulsions
(SECONDARY)
(duration)
yrs.
mos. ds.
18 Where was disease contracted
if not at place of death?
Prenatal
Did an operation precede death ?
(no Date of
Was there an autopsy ?
What test confirmed diagnosis ?
inone
(Signed)
Bitmel cal
M.I.D.
, 19 / 5(Address)
* State the DISEASE CAUSING DEATH, on in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Stimarys Quincy
DATE QF BURIAL Hab. 14/2018
20 UNDERTAKER John D. O'malley
ADDRESS
State
Dass.
.
Registered No.
or
(If non-resident give city or town and State)
Years
Months
Bangor.
/WyJd
V SI SIHL-XNI ONIOVINO HLIM XINIVIJ 3IHM
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupa- tion 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, Compos- itor, Architect, Locomotive 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; (o) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Forcınan," "Manager," "Dealer," etc., without more precise specification, as Day loborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Hlouscmoid, 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
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