USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 95
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years
months
days.
How loog in U. S., if of foreign birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Perale
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) Feb. 24,1918
7 AGE
Years
Months
Days
If LESS than 1 day, ........ hrs. or ....... min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
-
(b) Geoeral nature of industry,
business, or establishmeot in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town).
Chelsea
(State or country)
MasC.
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
12 MAIDEN NAME OF MOTHER Verna Harvey
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
Nova Scotia
14
Informant
(Address)
15
Filed Mar. 2319 18 Luc
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and ycar)
Mar. 18 1918
17 I HEREBY CERTIFY, That I attended deceased from February 24 18
19
to.
Mar. 18
18
19
that I last saw h.
E.f. alive on
Mar. 18
18
19
and that death occurred, on the date stated above, at
6 2.
m.
The CAUSE OF DEATH* was as follows :
Premature.
Ma rasmus
(duration)
-
-
.yrs.
... mos ...
22.ds.
CONTRIBUTORY
(SECONDARY)
(duration)
... yrs.
-
.. mos.
.ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
ITO
Date of.
-
Was there an autopsy ?.
NO
What test confirmed diagnosis ?
None
(Signed)
Arville E. Johnson
M.D.
- - , 19 ]&(Address "inthron St . ,Winthrop
* 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. (Sce reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Garden Cemetery
DATE OF BURIAL
Mar.23
19
20 UNDERTAKER C. II. Faunce
ADDRESS
Chelsea
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.
-
--
22
.. ,
(If non-resident give city or town and State)
- A
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 ina- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ctc., 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 liave no occupation whatever, write None.
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 discasc. 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 inere symp- toins or terminal conditions, such as " Asthenia,' "Aneniia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"" "Debility" ("Con-
genital," "Senile," ctc.), "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
on statement of cause of death approved by Committee
on Nomenclature of the American Medical Association.)
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, ctc.
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 FURTIIER STATEMENTS BY PHYSICIAN.
R 15. 1-'18. 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
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH Winthrop (No. 25 Villa ave . St. .Ward)
9589
(City or town [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Louise Marie Thomas 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband ] @RESIDENCE 25 Villa Que.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Weute
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manuel
6 DATE OF BIRTH
Jeff 13 1973
(Month)
(Day)
(Year)
7 AGE
46
.. yrs. .mos.
ds.
or ..... . min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work Harmange
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
London - Enfant -
10 NAME OF
FATHER
Henry . C. Pelham
PARENTS
12 MAIDEN NAME
OF MOTHER
Marie Louise adkins
13 BIRTHPLACE
OF MOTHER
(State or country)
London Sug
II THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Harry. M. Thomas
(Address)
25 Villa are
,5
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
March 20
191.0.
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : Poisoning by carbon mon- oxide presumably incidental to syncope caused by Chronic Endocarditis
(Duration)
.. yrs.
mos. .ds.
Contributory. (SECONDARY)
(Duration)
mos.
ds.
ffigned)
Ye
4.3. Surgens Magrath
MEDICAL EXAMINER
M.D.
* State the DISEASE CAUSING DEATII, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
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
3/22
191
20 UNDERTAKER
ADDRESS
1
If LESS than 1 day, ........ hrs.
11 BIRTHPLACE
OF FATHER
(State or country)
England
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, Architcet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line i 3 provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Groecry; (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, 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 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 (retircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- CASE 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 fcvcr (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("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 discase; 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- acmia" (merely symptomatic), "Atrophy," "Collapsc," "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. 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 cf head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
-
R. 16.8.'15. 5,000.
The Commonwealth of Massachusetts
Winthrop
BOSTON (City or town)
1 PLACE OF DEATH
County
Suffolk
State Massachusetts .. Registered No.
Township
Winthrop ..
or Village
City
BOSTON
No. 8 Edgehill Road
St., ........
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Mary M. Cook.
(a) Residence.
No.
8 Edgehill Road.
.St.,.
.Ward.
(If non-resident give city or town and State)
Leogth of residence io city or towo where death occurred
1
years
mooths
days.
How loog in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
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
William H. Cook.
6 DATE OF BIRTH (month, day, and year)
Mar 13 1848
7 AGE
70
Years
Months
0
Days
8
If LESS thao 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
none
(b) General oature of industry, business, or establishment in which employed (or employer) (c) Name of employer
-(duration)
yrs ...
mos ....
7
.ds.
CONTRIBUTORY
Grippe
(SECONDARY)
(duration)
yrs ..
.. mos.
10.ds.
...
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
Date of.
Was there an autopsy ?
no
FOR WHAT ?
What test confirmed diagnosis ?
Clerical
(Sigoed).
3/2.2. 1918 (Address)
Winthrop, Mass.
* 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~ Forest Hills
DATE OF BURIAL 3/24 1918
20 UNDERTAKER
Srlafirman &Sons.
ADDRESS
Boston
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
14
Informant
w. W.Cook.
(Address)
8 Edgehill Road.
15 Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and ycar)
March 21, 1918.
17
I HEREBY CERTIFY, That I attended deceased from
March
10.
. to Mar. 21dl
, 19.
,1918
, 1918.
that I last saw h/2
alive on
Mar. 21.
, 1918.
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows:
Buonahs- Pneumonia
9 BIRTHPLACE (city or town)Turkey
(State or country)
10 NAME OF FATHERJoseph Cochrane
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Gowanda N.Y.
12 MAIDEN NAME OF MOTHERDeborah Plumb
13 BIRTHPLACE OF MOTHER (city or town).
(State or count
Fredonia N.Y.
M.D.
STANDARD CERTIFICATE OF DEATH
.or
(Usual place of abode)
[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, 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 linc 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 houschold 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 .- 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 "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; Chronie 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," etc., when a definite discase can be ascertaincd as the cause. Always qualify all diseases resulting from child- birth or iniscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ctc. State cause for whichi 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.)
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 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
PIIYSICIAN.
-
1
-
R 15. 2-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County ..
Suffolk
State
Incest.
Registered No.
City
Winthings
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
Mary G. Broadhurst
(a) Residence.
No.
19 Cherry St.
St.,
Ward.
(Usual place of abode)
Length of residence in city or town where death occurred
days.
How long io U. S., if of foreigo birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowis
5a If married, widowed, or divorced HUSBAND of (or) WIFE of Windows James Boardman
6 DATE OF BIRTH (month, day, and year)
Months
73
1
Days
9
If LESS than
1 day, ........ hrs.
or ........ min.
Valvular Heart Disease
8 OCCUPATION OF DECEASED
(a) Trade, professioo, or
particular kind of work.
athome
9 BIRTHPLACE (city or town).
Finidad I. J.
10 NAME OF FATHER Jamie Fraccy
11 BIRTHPLACE OF FATHER (city of town). gratis
(State or country) wales
12 MAIDEN NAME OF MOTHER Caulfield
13 BIRTHPLACE OF MOTHER (eity or town) Umouts (State or country )(
14 Sangti. Stone
Informant (Address) 19 Chediyet Wiechers
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) March 21" 1918.
17
I HEREBY CERTIFY, That I attended deceased from
Mel 19'
19/8
Mch 21'
, 1918.
to
that I last saw her
alive on
mch 20"
, 1918.
and that death occurred, on the date stated above, at 5 a. m. The CAUSE OF DEATH* was as follows :
(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 ?
No
.Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
-
(Signed)
John S. Fischer
M.D.
3/21, 19/18 (Address) Fr. Bauke, Mare
* 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 spaee.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Halifax U. S.
DATE OF BURIAL 3-26 19/8
20 UNDERTAKER W.C. Skaggs
ADDRESS
Winthrop
Township 3 SEX 7 AGE Ycars (State or country) PARENTS 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. 15 Filed IN. D. - WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD. Every item of information should be (h) Geoeral oature of industry, business, or establishment in which employed (or employer) (c) Name of employer
........ , 19
Broadhurst
(If non-resident give eity or town and State)
TWOMITT STATS STANDARD D CERTIFICATE OF BEATIE
[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, 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,"
"Foreinan,' "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.
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