USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 97
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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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH Lock, County
State
Registered No.
or Village.
or
No.
42
St.,
. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Robert. Hendrich. Hollles
(a) Residence.
No.
42 trunklan
St.,.
.Ward.
(Usual place of abode)
(If non-resident give city or town and Stato)
Length of residence in city or town wbere death occurred 1 years X months 2 days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
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)
Ycars
8
Months
X
Days
28
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
School Boy
9 BIRTHPLACE (city or town) ..
(State or country)
10 NAME OF FATHER Robert. S. Fouller
11 BIRTHPLACE OF FATHER (city or town) ..
(State or country) man
12 MAIDEN NAME OF MOTHER Dani BNenhof 3/2, 1918 (Address)
Bacon
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
man
14 Fuchan-
(Address)
42 Franklin Shawnthe
Filed 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
april
1
19 / 8.
17
I HEREBY CERTIFY, That I attended deceased from
,19
to
19.
.
that I last saw h .....
alive on
19
and that death occurred, on the date stated above, at
6
9.
The CAUSE OF DEATH* was as follows :
From natural Causes
(duration)
yrs.
.mos ...
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
yrs ... .
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
Date of.
Was there an autopsy ?.
nondumed rue. Ly,
What test confirmed diagnosis ?
med. Exaturner.
(Signed)
Milligra fo Paris
I.1.D.
Minutiask Ich. Board of Alewis
* 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
4,3
ADDRESS
20 UNDERTAKER
3-R. Remini
.. mos.
ds.
Jasam: Plan
Township 3 SEX male 7 AGE (a) Trade, profession, or particular kind of work PARENTS Informant 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. 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, or establishment in which employed (or employer) (c) Name of employer
City 2
[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 terin 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 DEATII, 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 DEATHI (the primary affection with respect to time and causation), using always the same accepted terin for the same disease. Examples: Cerebrospinal ferer (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-
toins or terminal conditions, such as
"Asthenia,"
"Col- "Anemia" (merely symptomatic), "Atrophy,"
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 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
ou 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
PHYSICIAN.
R 15. 1-'18. 100,000.
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
PARENTS
12 MAIDEN NAME
OF MOTHER
mary
Lyons
13 BIRTHPLACE
OF MOTHER
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
J. J. Schrift.
(Address)
19 Wehtun an
15 Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
1ª DATE OF DEATH
april
(Month)
(Day)
1
(Year)
17 I HEREBY CERTIFY that I attended deceased from Fely 27, 1918, to april-1 1918 ..........
that I last saw herecalive on
1918
and that death occurred, on the date stated above, at.
650pm
The CAUSE OF DEATH* was as follows :
Perminara Guarmia
Did a surgical operation precede death? to Date
....
Contributory.
Security
(SECONDARY>
Owiele & Colcuore
(Signed)
...
M.D
afree 3, 1918
(Address)
.....
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
:8 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
.yrs.
.mos.
In the
ds.
State ............ yrs,
mos.
ds.
......
..........
Where was disease contracted, If not at place of death ?..
Former or usua, residence.
19 PLACE OF BURIAL OR REMOVAL Calvary
DATE OF BURIAL
191
20 UNDERTAKER
ADDRESS
BOSTON (City or town.) [If death occurred in a hospita or institution, give its NAME Instead of street and number.]
"FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
19 Rupture an Authorof
PERSONAL AND STATISTICAL PARTICULARS
* SEX
{ COLOR OR RACE
Uhito
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
' DATE OF BIRTH
(Month)
(Day)
1
(Year)
, AGE
If LESS than ( day ......... hrs.
......... yrs.
mos.
ds.
or ...
... min. ?
& OCCUPATION
Curl war Veteran.
(a) Trade, profession, or
particular kind of work
Retired,
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
10 NAME OF
Cuke Leyons
11 BIRTHPLACE
OF FATHER
(State or country)
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
[5-'17-XXM.} The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
7PLACE OF DEATH Deathrow .. ( N /a Neptune are
: ............. Ward)
Thomas F. Lyons
.... Registered No.
L. 191.
8
.. yrs. ....... - .... TITOS. ................ 03.
.yrs. ....... mos. ................ ds.
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, Architeet, 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) Forcman, (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, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATII, 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 cccu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cerebro-spinal fevcr (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," unqualificd, 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 neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmnia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septieacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
៛ 1. 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 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, cte.
R. 15. 1-'17 100,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Winthrop. BOSTON
(City or town)
1 PLACE OF DEATH
County
Suffolk
State.
Massachusetts ...... Registered No ..
Township
Winthrop
or Village
or
City.
BOSTON-
No.
35 Lincoln Street
St.,
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Hattie E. Allen
(a) Residence.
No.
35 Lincoln Street
St.,
Ward.
(If non-resident give city or town and State)
Length nf residence in city or town where death occurred
6
years
months
days.' How long in U. S., if of foreign birth ? years
months days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married.
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Claude D. Allen
ct 29 1872.
6 DATE OF BIRTH (month, day, and year)
Years 45
Months
5
Days
10
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
Lansing N.Y.
9 BIRTHPLACE (city or town)
(State or country)
10 NAME OF FATE
John W. Collins.
11 BIRTHPLACE OF FEUsing N.Y.
(State or country)
12 MAIDEN NAME OF MOTHER Julia
Turpening9, 19/8 (Address)
13 BIRTHPLACE OF MOLUNgingWN . Y. (State or country)
14 blande O allen
(Address)
35 Cmcola Et Nin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, AP,El Lar8 1918
19
17
J HEREBY CERTIFY, That I attended deceased from
Ich. 15
19.19, to
afr 9.
1918.
that I last saw
-
alive on
ahr. 8.
, 1918.
and that death occurred, on the date stated above, at 11 9. m. The CAUSE OF DEATH* was as follows :
bar cename ( of neck and
secutiple carenormato
(duration)
3
yrs (21
CONTRIBUTORY
(SECONDARY)
.mos.
ds.
aceite nephritis
(duration)
2
............ yrs ....
mos.
ds.
if not at place of death ?
Did an operation precede death ?
200.
„Date of.
Was there an autopsy ?
no.
FOR WHAT ?
What test confirmed diagnosis ?
Clinical
Signed)
M.C. Porto
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
Groton N.Y.
DATE OF BURIAL
4/12
19
18
20 UNDERTAKER
gratinnantais
ADDRESS
Boston
.
(Usual place of abode)
white
3 SEX female 7 AGE (a) Trade, professinn, or particular kind of work. PARENTS Informant 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 N. B. - WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD. Every item of thformation should be (b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
...... , 19
18 Where was disease contracted
[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 Inany occupations a single word or terin 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 Ilousekeepers 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, Cool:, 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- eated 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 (thie 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 "Tuinor" 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: Mcasles (disease causing deatlı), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- tomns or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Comna," "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 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 (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 onc supposed to bc due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PIIYSICIAN.
+
R 15. 2-'18. 100,000.
The Commonwealth of Massachusetwinthrop STANDARD CERTIFICATE OF DEATH
BOSTON (City or town)
1 PLACE OF DEATH
County
Suffolk
State
Massachusetts ...... Registered No ..
Township
Winthrop
or Village
or
City
BOSTON
No.
Cliff House.
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Mary E. Seignious.
(a) Residence.
No.
Cliff House.
.St.,
.......
.. Ward.
(If non-resident give city or town and State)
Length of residence io city or town where death occurred
3
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Cefar. 8. 1918.
, 1918
to.
17
I HEREBY CERTIFY, That I attended deceased from
March
7.
apr. 7
, 19 18
that I last saw her
alive on
9.18.
and that death occurred, on the date stated above, at
11.00
m.
The CAUSE OF DEATH* was as follows :
(duration)
.yrs.
mos.
ds.
CONTRIBUTORY
Organic Heart Decease
SECONDA deff/
(duration)
.yrs ..........
.. mos.
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
24 - Date of
-
Was there an autopsy ?
FOR WHAT ?
no.
What test confirmed diagnosis ?
Clinical
(Şigned)
Mr.f. Parte
Женевнор, тоя.
* 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.)
14 William Segniour
(Address)
Hiff Hforce. Winthrole
15 Filed , 19
REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Forest Hills
DATE OF BURIAL
4/10
1918
20 UNDERTAKER
Firman Sous
ADDRESS
Boston
3 SEX female 7 AGE Years 64 (a) Trade, profession, or particular kind of work (State or country) PARENTS Informant 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. N. B. - WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD. Every item of information should be (b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or
Charleston S.C.
10 NAME OF FATHER
Alexander F.Black.
11 BIRTHPLACE OF FATHER (city or town) Unknown
(State or country)
12 MAIDEN NAME OF MO Elizabeth Marston8,19/8 (Address)
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Days
16
If LESS than 1 day, ........ hrs. or ....... min.
8 OCCUPATION CF DECEASED
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married.
5a If married, widowed,por diverced
HUSBAND of
(or) WIFE of
William
6 DATE OF BIRTH (month, day, and year) Dec 22 1853.
Months
3
35
M.D.
(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 ean be known. The question applies to cach and every person, irrespective of age. For inany occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engincer, 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," "Forcman," " 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 wlio 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 domnestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or giversup 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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