USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 92
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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- loneum, 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 .; Broneho- pneumonia (secondary), 10 ds. Never report mere symp- toms 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," "Uremia," "Weakness," cte., when a definite disease 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 dle- 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
Cases 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 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.
ADDITIONAL SP
FOR FURTHER STATEMENTS
BY
PHYSICIAN.
.
R 15. 1-'18.
10,000.
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
I PLACE OF DEATH Mitturp 2 FULL NAME {If married or divorced woman or widow give maiden name, also name of husband. ] $ SEX COLOR OR RACE Make whito 7 AGE & OCCUPATION (a) Trade, profession, or (b) General nature of industry, business, or establishment in which employed (or employer). PARENTS 13 BIRTHPLACE OF MOTHER (State or conntry) important. See instructions on back of certificate. 16 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 particular kind of work none
[5-'17-XXM ] The Commomuralth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No Cultiex Taff
St. . Ward)
Adams
@RESIDENCE Beacon Chambers Ingetly St., Boston
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE. MARRIED, WIDOWED. OR DIVORCED (Write the word)
Married TO DATE OF DEATH
· DATE OF BIRTH Leke. 13 18561 (Month) (Day) (Year)
If LESS than 1 day ......... hrs.
61 yrs. 5 mos. 13 ds.
or ......... min. ?
9 BIRTHPLACE
(State or country)
Castan Make.
10 NAME OF
FATHER
Joshua Webb Adams
11 BIRTHPLACE
OF FATHER
(State or country)
Brunswick, Me.
12 MAIDEN NAME
OF MOTHER
Hanmah Maña Fall
Brunswick me.
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mr. Frederick L. Carga
(Address)
Bastan Mass Brunswick, Maine
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
Feb. 26.
1918
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
nov 19
191
7
......
to
Feb 20-
191.2.
that I last saw hami
alive on
Teb 25:
1918
and that death occurred, on the date stated above, at
a. m.
The CAUSE OF DEATH* was as follows :
Cirrhosis of the finis
Did a surgical operation precede death ?
200
Date
(Duration) .yrs.
mos. da.
Contributory.
Chronic alcoholismo
(SECONDARY)
26-
(Duration)
.yrs.
mos.
ds.
(Signed)
Letilice Douglas adams Mat
Feb 26, 1918. (Address) 175 Dartmouth St.
* If death followed injury or violence the certificate of death inust 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. .........
In the
mos. ............
ds .............
Where was disease contracted,
If not at place of death ?...
Former cr usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
2
1910
20 UNDERTAKER
ADDRESS
232 Huntington
r
.
BOSTON
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
.... Registered No.
A PERMANENT RECORD.
SI SIHL ANI UNIOYJ
N. B. - WRITE PLAINLY, WITH UNF
Fel . 26,1918 STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precisc 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. - Namc, first, the DIS- EASE CAUSING DEATHI (thc 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 cercbro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- nncumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, 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- aemia" (mcrcly symptomatic), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition;" "Marasmus," "Old agc," "Shock," "Uraemia," "Weakness," etc., when a definite discase can be ascertained as the causc. Always qualify all discases 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, 1 Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
4 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.
1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County.
Suffolk
State
quais
Registered No .. .....
or Village.
or
City
Winthrop
No ..
68, Park ave
St., ..
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
alfred J. Nelson
(a) Residence.
No.
168 park ave.
.St.,
.......
Ward.
(Usual place of abode)
Length 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
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Unknown
6 DATE OF BIRTH (month, day, and year)
Months
8
Days
14
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Piano Maken
9 BIRTHPLACE (eity or town)
(State or country)
10 NAME OF FATHER John nelson
11 BIRTHPLACE OF FATHER (eity or town) ..
(State or country)
Surden
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
Informant
no. Hanr. Kelly
(Address)
68 Pack avz.
Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
2-28
19/9
17 I HEREBY CERTIFY, That I attended deceased from July 2 5 am/ 2018, to Zely 280man 1 015
that I last saw
alive on
Files 28
, 19 18
and that death occurred, on the date stated above, at
8 00
The CAUSE OF DEATH* was as follows :
Cerebral Hoewomboge
12 hours
(duration)
.. yr's
.de.
CONTRIBUTORY
artene- sclerosis
(SECONDARY)
Several
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
nu Date of.
X
Was there an autopsy ?
200
What test confirmed diagnosis ?
(Signed)
Owiele & Jolis
3/1: 19/8 (Address)
mais
* 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 spaec.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
>
Fair View Hydepark
DATE OF BURIAL 3-2-19/8
ADDRESS
20 UNDERTAKER
U.S. Skaggs
.yrs.
moswords.
X
II.D.
Township 2 FULL NAME 3 SEX 7 AGE Years 81 PARENTS 14 so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back of certificate. carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, 15 N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (b) General nature of industry, business, nr establishment in which employed (nr employer) (c) Name of employer
(If non-resident give city or town and State)
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 iniportant, 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, 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 wlien necded. 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.
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 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 symp- toms 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,"" "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 onc supposed to bc due to Alcoholism, etc.
4. Deatlrs 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
RITA COUGHLIN
Registered No.
2617
Place of Death / and Residence 1 Date of Death
Boston
FEB.28
ST . MARYS HOSPT . 1918, Age
years
9
months
1
days.
STATISTICAL DETAILS.
SEX
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
S
Maiden Name
Husband's Name
Birthplace
BOSTON
Name of Father
Birthplace of Father
Contributory: (Duration)
-
Maiden Name of Mother
MARGARET COUGHLIN
Birthplace of Mother
BOSTON
R.M.MERRICK
(Signed)
M.D
1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
ST.JOSEPHS CEM.
Undertaker E.L.BEAN
Filed
MAR.8
1918.
A true copy.
Attest :
QUINCY
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness, from 1918, to
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:
ISTRAR
PATRIBUS
Primary (Duration)
CITY
OFFICE
MEASLES-8 DYS
BRONCHO-PNEUMONIA - 8 DYS
VITA
BOSTONIA CONDITAL.
D. 1822.
18 81.
MINE DUNATA A
ST
N. MASS
Occupation
Informant
Usual Residence
WINTHROP
Registrar.
R
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERM. INENT RECORD. Every
RMANENT
itor
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
14
Informant
Philip J. Cumland
(Address)
123 During an
15
Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and ycar) march 1 1918
19 17 I HEREBY CERTIFY, That I attended deceased from , 19 , to
that I last saw h ..........
alive on
19
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Macerated foetus, had
reen dead over a week
when born.
(duration)
CONTRIBUTORY
(SECONDARY)
(duration)
yrs ..
mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
no Date of
Was there an autopsy ?
no
What test confirmed diagnosis ?
Franck & Baleman
(Signed)
M.D.
19
(Address)
Sommerville, masz.
* State the DISEASE CAUSING DEATHI, 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, OK REMOVAL
Warchest Camely
DATE OF BURIAL
3/11
19!
20 UNDERTAKER
ADDRESS
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County.
Nuflock
State
Registered No.
Township
Wencheof
or Village No Metcal Hospital Wiechers.
or
City
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Still Bowl
(a) Residence.
No ...
123 Juiny ave. St.
Ward.
(If non-resident give city or town and State)
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
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
Years
Months
Days
If LESS thao 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kiod of work
(b) General nature of indostry,
business, or establishment io
which employed (or employer)
(c) Name of employer
1
9 BIRTHPLACE (city or town) Wenchert (State or country) Más
PARENTS
10 NAME OF FATHER Seo. G. Roberts
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
12 MAIDEN NAME OF MOTHER Mildred Ju .
13 BIRTHPLACE OF MOTHER (city or town)
(Statc or country) Beachmont mar
mooths
months
Ward
(Usual place of abortc)
Length of residence io city or towo where death occurred
years
days.
How long in U. S., if of foreign birth ?
years
.. yrs.
mos.
ds.
maceration
CORD. A PERMANENT REC
SI SIHL-XNI ĐNIGVANN HLM XINIVId 3LIỀM-8 *N
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, c. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotivc 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) Salcsman, (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 laborcr, Farm laborer, Laborer - Coal mine, etc. Women at liome, who are engaged in the duties of the household ouly (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.
Statement of cause of death .- Naine, first, the DISEASE CAUSING DEATH (the primary affeetion 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, ete., Carcinoma, Sarcoma, ete., of_
(namne origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. 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 niere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy,'
lapse," "Coma," "Convulsions," "Debiliy "Col- ("Con- genital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," ^Inanition," "Maras- Inus," "Old age," "Shock," "Uremia," "Weakness," ete., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State eause 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 fraeture 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 eliapter 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, ete.
2. Deaths supposedly eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be duc to Alcoholism, etc.
4. Deaths under eireumstanees unknown, as A person found dead, ete.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
-
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Hintlirah (City or town)
County
Township
City
(If death occurred in a hospital or institution, give its NAME instead of street and number)
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