USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 91
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Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
Portland ME
20 UNDERTAKER
W.C. Skaggs
ADDRESS
Wusthof
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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. Sec instructions on back of certificate.
PARENTS
12 MAIDEN NAME
OF MOTHER
arm Durand
13 BIRTHPLACE
OF MOTHER
(State or country)
novascotia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. Sampson
(Address)
3/ Orange St. Chelsea
15
Filed ......... -, 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jule
(Month)
(Day)
22
191. (Year,
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : Chatural Causes, Character in determinate.
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Nova Scotia
10 NAME OF
FATHER
Benjamin Bracon
11 BIRTHPLACE OF FATHER (State or country) Novascotia
9512
Winterof (City or to v.) [If death occurred in e hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
(No.
19
St. ...... .. Ward)
DATE OF BURIAL
2-200
Jomb, 1918
M.D.
In the
AJJAJ
ANENT RECORD. PERMAN
V SI SIHL - XNI DNIOVANA HLIM ANNIVIA BLIUM -- EN
Feb. 22, 1918
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preeise 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 terin on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fircman, 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) Forcman, (b) Automobile factory. The material worked on inay form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborcr, Farm laborer, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At homc. Care should be taken to report specifically the occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, ete. 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 oeeu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATHI (the primary affection with respect to time and causation), using always the same accepted terni for the same disease. Examples: Cerebro-spinal fcvcr (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 indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, ete., 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: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease ean 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. For VIOLENT DEATHS state 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 hcad - 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- posure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or onc supposed to be due to Alcoholism, etc.
4. Deaths under eircumstances unknown, as A person found dead, ete.
R 16. 10-'17. 10,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or towu)
1 PLACE OF DEATH
County
Luffolk
State
Registered No.
Township
or Village.
or
City
No ..
106 Washington Que
St.,
......
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(a) Residence.
No ..
106 Washington Give
... St.,.
Ward.
(Usual place of abode)
Length of residence in city or town wbere deatb occurred
8%.
years
months
-
days .
~ How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
-
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE 80 Years
Months
4
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Retired Dry Food Ligt
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
Stowe Mass
(State or country)
10 NAME OF FATHER
Pilar Store
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
Waren
(State or country)
12 MAIDEN NAME OF MOTHER Phcole Pardon
Marie
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Fel 24
19 / 50
17
I HEREBY CERTIFY, That I attended deceased from
21
to.
19/8
that I last saw h
im alive on
Juh 24
19.18
and that death occurred, on the date stated above, at
83640
m.
The CAUSE OF DEATH* was as follows :
5
war of Lungs.
¥
(duration)
... yrs ..
....
.mos ....
ds.
CONTRIBUTORY
(SECONDARY)
.(duration)
.. yrs ..... ......... mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
Date of
Was there an autopsy ?.
What test confirmed diagnosis ?
(Signed)
:I.D.
27 95 19/ 6 (Address), * 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
Old Town Marine
DATE OF BURIAL
Fiely 26
10/8
20 UNDERTAKER
ADDRESS
15 Filed 19
REGISTRAR
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. N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be .
14
Informant
Low .I Store
(Address)
Stone
(If non-resident give city or town and State)
N
REVISED UNITED STATES STANDARD CEPTI ARD 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 terin on the first line will be sufficient, c. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobilc 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 minc, 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 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 (rctired, 6 yrs.). For persons who have no occupation whatever, write Nonc.
Statement of cause of death .- Namne, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and eausation), 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- toneum, etc., Carcinoma, Sarcoma, ete., of.
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broneho- pneumonia (secondary), 10 ds. Never report mere symp- toins or terminal 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," "Old age," "Shock," "Urcmia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ctc. 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 (e. 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.
AGE shoul
,
WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of infor
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
......
Winthrop (City or town)
Registered No.
or Village
or
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Arthur John Verdi
(a) Residence.
No.
85 Bowdoin St
St.,
.. Ward.
mooths
days.
How loog in U. S., if of foreigo birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
Seht 17, 1916
Days
If LESS thao 1 day, ........ hrs. or ....... min.
England
Vedbello Hall
13 BIRTHPLACE OF MOTHER (city or town) (State or country) Amaral
Haverhill
(Address)
85 Bowdown St Wardlunch
15
Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Jeb. 25 1918
17 HEREBY CERTIFY, That I attended deceased from
19 .. £
26.25
.19/8
to
.
that I last saw h Wwalive on
, 1916
and that death occurred, on the date stated above, at
1A
..... m.
The CAUSE OF DEATH* was as follows :
(duration)
yrs ..
mos ..
ds.
CONTRIBUTORY
Pertussis
(SECONDARY)
(duration)
yrs .....
mos ..
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
10
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
Charles i mahoney
2/26, 19/6 (Address)
356 Unulhorbit.
* State the DISEASE CAUSING DEATH, or in deaths fron 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
Favizur Hyde Paule
DATE OF BURIAL
2/27
1948
20 UNDERTAKER
John f: Q Inaley
ADDRESS
Winthrop
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be
1 PLACE OF DEATH
County ...
Suffolle.
Township
Monthof
City
(Usual place of abode)
Length of residence io city or town where death occurred
years
3 SEX
Male
4 COLOR OR RACE
White
5a If married, widowed, or divorced
HUSBAND of
(01) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
Months
17
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particolar kind of work
(h) General oature of iodostry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town).
Winthrop
10 NAME OF FATHER
Walter
11 BIRTHPLACE OF FATHER (eity or town)
(State or country)
12 MAIDEN NAME OF MOTHER
PARENTS
14
Informant
Isabell @ Stall
of certificate.
& carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
"4so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
(State or country)
maks
State
mare
No.
(If non-resident give city or town and State)
Date of.
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; (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 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 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nous. ..
Statement of cause of death. - Name, 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 "Epidemie 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- toneum, 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 symnp- toms or terminal conditions, such as " Asthenia," "Anemia" (increly symptomatic), "Atrophy," "Col- lapse," "Coma," ""Convulsions," "Debility" (“Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can 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 (e. 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
CHARLES I. JACOBS
Registered No. 2402
Place of Death
Boston
and Residence
Date of Death
FEB.25
1918,
Age
56
years 2
months 14 days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID .. DIV.
M
M
I HEREBY CERTIFY that I attended deceased during last illness, from 1918, to
Maiden Name
STRAR
Husband's Name
UT PATRI
Primary (Duration9
INTERNAL INJURIES CAUSED BY A
Birthplace
LYNN
Name of Father
EDWARD S. JACOBS B
Birthplace of Father
LYNN
Contributory : (Duration )
Maiden Name of Mother
HARRIET WASHBURN
Birthplace of Mother
TAMWORTH.N.H.
(Signed)
G.B.MAGRATH MED.EX. M.D.
FEB.26918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
LYNN(PINE GROVE CEM)
Usual Residence
WINTHROP ( 135 QUINCY AVE)
Undertaker
J. M. BLAISDELL
Filed
MAR . 5
1918.
LYNN
A true copy. Attest :
Registrar.
CITY
OFFICE
MACHINERY ACCIDENT
CTVITA BOSTORIA CONCITAA.
ATI TO ISREGIMINE DONATA A. 1831. MASS.
Occupation SALESMAN
Informant
PHYSICIAN'S CERTIFICATE.
1918, that to the best of my knowledge and belief death occurred, on the date stated above, and that the CAUSE OF DEATH was as follows:
B.C.H.RELIEF STA.
diebruary 25. 1918
N. B. WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD oprofully supplied. AGE
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. Exaot 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 Geo It- Verdi
(Address)
15
19 18
TR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Ler. 25 19/
17 I HEREBY CERTIFY, That I, attended deceased from
70.5.25-1918.
11.2.15/17.19.
.......
to
that I last saw h alive on ,19 ..
and that death occurred, on the date stated above, at
410 m. The CAUSE OF DEATH* was as follows :
(duration)
8
.mos ...
0
...... yrs .....
ds.
CONTRIBUTORY
(SECONDARY)
(duration) ............ yrs ................. mos. .......
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death?
Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
Felix
5
11
7
M.D.
/s. 19/ (Address)
* 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 Fairinzer feu
DATE OF BURIAL
19
1
20 UNDERTAKER
ADDRESS
Filed ....
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
Months
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
N
Classé
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
(State or country)
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country) Cé-2 - It race of
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (city or town) (State or country)
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Cartridge (City or town)
1 PLACE OF DEATH
County.
722000
State
Registered No ..
315
Township
City . de hartre
No.
por Village.
or
.St.,
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Valle Verdi
(a) Residence.
No.
(Usual place of abode)
Lengtb of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
St., ..
„Ward .-
-
(If non-resident give city or town and State)
3 SEX
33
0
0
(a) Trade, profession, or
particular kind of work
KEVISLD UNITED SIAIUS STANDARD CERTIFICATE OF DEATH (Approved by U. S. Census and American Pablic Health Association]
under the head of ".Contributory . WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD. on statement of cause of death approved by Committee on Nomenclature of the American Medical 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, Architeet, 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 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 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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