Town of Winthrop : Record of Deaths 1919-1921, Part 198

Author: Winthrop (Mass.)
Publication date: 1919
Publisher:
Number of Pages: 1192


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1919-1921 > Part 198


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93 | Part 94 | Part 95 | Part 96 | Part 97 | Part 98 | Part 99 | Part 100 | Part 101 | Part 102 | Part 103 | Part 104 | Part 105 | Part 106 | Part 107 | Part 108 | Part 109 | Part 110 | Part 111 | Part 112 | Part 113 | Part 114 | Part 115 | Part 116 | Part 117 | Part 118 | Part 119 | Part 120 | Part 121 | Part 122 | Part 123 | Part 124 | Part 125 | Part 126 | Part 127 | Part 128 | Part 129 | Part 130 | Part 131 | Part 132 | Part 133 | Part 134 | Part 135 | Part 136 | Part 137 | Part 138 | Part 139 | Part 140 | Part 141 | Part 142 | Part 143 | Part 144 | Part 145 | Part 146 | Part 147 | Part 148 | Part 149 | Part 150 | Part 151 | Part 152 | Part 153 | Part 154 | Part 155 | Part 156 | Part 157 | Part 158 | Part 159 | Part 160 | Part 161 | Part 162 | Part 163 | Part 164 | Part 165 | Part 166 | Part 167 | Part 168 | Part 169 | Part 170 | Part 171 | Part 172 | Part 173 | Part 174 | Part 175 | Part 176 | Part 177 | Part 178 | Part 179 | Part 180 | Part 181 | Part 182 | Part 183 | Part 184 | Part 185 | Part 186 | Part 187 | Part 188 | Part 189 | Part 190 | Part 191 | Part 192 | Part 193 | Part 194 | Part 195 | Part 196 | Part 197 | Part 198 | Part 199 | Part 200 | Part 201 | Part 202 | Part 203 | Part 204 | Part 205 | Part 206 | Part 207 | Part 208 | Part 209 | Part 210 | Part 211 | Part 212


Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise a description of such person as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are supposed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.


RULES OF PRACTICE


The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:


(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.


(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.


(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused dircetly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or clectrical agents, and deaths following abortion, but also deaths fron disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


MR-303


The Commonwealth of Massachusetts


MEDICAL EXAMINER'S CERTIFICATE OF DEATH


OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS


1 PLACE OF DEATH


(ISSUED UNDER THE PROVISION OF REVISED LAWS, CHAPTER 24)


County ..


Suffolk


E NulPROVES notifica State


Registered No.


163


St.,


Ward


2 FULL NAME


Edward


(If death occurred ip m hospital or institution, give its NAME instead of strect and number) Leight -


(Ifin the Army or Navy of the United States, give rank, organization, etc. )


(a) Residence.


No. ..


Last milla


(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


3 SEX


MALE


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


MILDRED


YOUNG LEIGHTON


6 DATE OF BIRTH


( Month)


(Day)


(Year)


7 AGE


34


Years


Months


Days


If LESS than


1 day, ...... hrs.


or ....... min.


8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work. SALESNIAN


(b) General nature of industry,


business, or establishment in


which employed (or employer)


(c) Name of employer


9 BIRTHPLACE (City)


CHICAGO


(State or country)


10 NAME OF


FREDICK T. LEIGHTON


FATHER


11 BIRTHPLACE OF


FATHER


(City )


NEW YORK


(State or country)


NY. Y.


12 MAIDEN NAME


OF MOTHER


MARY CLARK


13 BIRTHPLACE OF


MOTHER (City)


CLEVELAND


(State or country)


OM10


(Day)


( Year )


14


Informant


URS MILDRED LEIGHTON


(Address)


19 NORWOOD


ST EVERETT.


15


Nov. 3.1921


Filed


(Month) (Day) ( Year)


REGISTRAR


21 Burial permit


issued by


Official position


(See reverse side for description for unknown person) ...


18 Where was injury sustained if not at place of death ?...


(Signed)


Burgers Month.


.. , M.D.


Suffolk


Date


Medical Examiner for.


Oct 27h


(Month)


1921


19 PLACE OF BURIAL, CREMATION, or REMOVAL


new Calvary Centry In Rox


(Cemetery)


(City or town)


20 UNDERTAKER


22 Date of


issue


Cr 27,21.


DATE OF BURIAL Lect 291921 (Month) (Day) (Year) ADDRESS mass


Permit No 19231


MARGIN RESERVED FOR DINDING


should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms, N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information for extracts from the laws relative to the return of certificates of death. so that it may be properly classified under the International Classification of Causes of Death. See reverse side


City or Town


Walking - ambulance of Winthrop Police.


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH.


Oct.


2)


(Month)


(Yay)


1921


( Year)


-


If STILLBORN, enfer that fact bere


If STILLBORN, state period of uterogestation


months


17 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows : Fracture of the skull with associated Chaemontage. Subdural and freud of the Grain Sustained under Circumstances un m.


PARENTS


11,957


. St., ..


.Ward.


( If non-resident give city or town and State)


EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH


A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a stand- ard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last scen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 322.


No undertaker or other person shall bury a human body until he has received a permit from the board of health or its agent, . . . or from the clerk of the city or town in which the person died; no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written state- ment containing the facts required by law to be re- turned and recorded, which . .. shall be accompanied by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hcrein- after provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. ... The persen to whom the permit is so given and the physician who certifies to the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.


Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise


a descriptio. of such person, as full as may be, with the cause and manner of his death, and shall inake examination upon the view of the dead bodies of only such persons as are sup- poscd to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.


RULES OF PRACTICE


The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:


(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from discase unrelated to any form of injury.


(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.


.


(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from in- jury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


STATEMENT OF CAUSE OF DEATH


Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause, the nature of an injury and of its consequences; and (2) under manner, the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a steam railway accident." "Pistol shot wound of the chest with associated hemorrhage, homi- cidal." "Asphyxiation by suspension, suicidal." "Syn- cope while under the influence of ether administered as a surgical anæsthetic." "Fracture of the skull with associated internal injury sustained under circumstances unknown."


If investigation shows the death to have been due to dis- ease, specify: (1) Under cause, its known or presumable nature; and (2) under manner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous, of the brain (basal gangloid) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"


DESCRIPTION (for unknown person)


Oct. 27.1921


NOTICE TO UNDERTAKERS : No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have come to his death by violence, until a permit in writing, signed by the Medical Examiner, has first been obtained. - Revised Laws, Chap. 24, Sec. 20.


THIS CERTIFICATE CONSTITUTES SUCH PERMIT


R-301


OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS


STANDARD CERTIFICATE OF DEATH


......... (City or Town)


1 PLACE OF DEATH County


State


No. 19. Whichorte Ihr


St ..


Ward


(If death occurred in a hospital or institution, give its NAME instead of street and number)


Frederick aller T field


2 FULL NAME


(a) Residence.


No.


19 Wheelock.


St., ..


Ward.


(If non-resident give city or town and State)


Leogth of resideoce in city or town where death occorred


20


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) Manuel


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


6 DATE OF BIRTH


- 2200 1 6 - 1850 ( Month)


(Day)


(Year)


Years


Months


.Days


15


If LESS thao 1 day ......... hrs. or ....... min.


If STILLBORN, enter that fact here


8 OCCUPATION OF DECEASED


(a) Trade, profession, or


particular kind of work


Gering Tender.


(duration)


1


... 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 ?


20


Was there an autopsy ?


What test confirmed diagnosis ?


(Signed)


M.D.


(Address).


174


Date. vet 31' 1921


( Month)


(Day)


(Year)


14 СК ,Зимин


19 PLACE OF BURIAL, CREMATION, OR REMOVAL ИтериТ


DATE OF BURIAL 2200 12/1926


(Cemetery) teresa (city or town)


20 UNDERTAKER 7


ADDRESS


Filed (Month) (Day) (Year)


REGISTRAR


21 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued


S.a. Poury


Official- position


Wealthofficeof permit


Date of issoe 11/1/21


Permit


345


No.


000


3 SEX Male 7 AGE 10 NAME OF FATHER PARENTS Informant (Address) should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH (b) Name of employer instructions and extracts from the laws on back of certificate. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See


MEDICAL CERTIFICATE OF DEATH


oct.


30


1421


16 DATE OF DEATH


(Month)


(Day)


(Year)


17 I HEREBY CERTIFY, That I attended deceased from may to 1921 art 30' 1921


that I last saw h ...


Q . alive on


Gal 29'


1941.


and that death occurred, on the date stated above, at


630 4 m.


The CAUSE OF DEATH was as followss Chronic interstitial heptoutes


9 BIRTHPLACE (City)


(State or country)


11 BIRTHPLACE OF


FATHER (City ).


(State or country)


mensfield.


12 MAIDEN NAME


OF MOTHER


13 BIRTHPLACE OF MOTHER (City) (State or country)


15 Nov. 3.1921


The Commonwealth of Massachusetts


Registered No.


164


City or Town


(If in the Army or Navy of the United States, give rank, organization, etc.)


( Usual place of ahode)


318 metcalf


Date of


ILLTDCD UNTIED SIAIES STANDARD CERTIFICATE OF DEATH


[Approved by U. S. Census and American Public Health Association]


Statement of occupation. - Precise statement of occupation 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, Locomotive engincer, Civilengineer, 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 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 house- hold 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, 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 fact may be indicated 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: Cere- brospinal fever (the only definite synonym is "Epidemio cerebrospinal meningitis"); Diphtheria (avoid uso of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia )- ("Pneumonia," unqualified. 's indefinite); Tuberculosis of lungs, men- inges, peritoneum, etc., Carcinoma, Sarcoma, etc., of .......... (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.


State cause for which surgical operation was undertaken.


(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)


Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.


Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.


4


EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH


A physician or registered hospital medical officer shall forthwith, after the death of a person whoin he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deccased, furnisli for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deccased, his supposed age, the disease of which he dicd, defined as re- quired by section one, where same was eontracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. ...- Gen. Laws, Chap. 46, Sec. 9.


No undertaker or other person shall bury a human body . . . until he has received a permit from the board of health or its agent . . . or ... from the clerk of the town where the person dicd; . . . No such permit shall be issued until there shall have been delivered to such board, agent or clerk ... a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original interment, by a satisfactory certi- ficate of the attending physician, if any, as required by law, or in licu thercof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physi- cian who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certi- ficate. ... The person to whom the permit is so given and the physi- eian ecrtifying the cause of death shall thereafter furnisli for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which tho clerk or registrar may require. - Gen. Laws, Chap. 114, Sec. 45.


Medical examiners shall make cxamination upon the view of the dead bodies of only such persons as are supposed to have died by violence. - Gen. Laws, Chap. 38, Sec. 6.


. .. He shall in all cases certify to the town clerk or registrar in the placo where the deceased died his name and residence, if known; other- wise a description as full as may be, with tho eause and manner of death. - Gen. Laws, Chap. 38, Sec. 7.


RULES OF PRACTICE


The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:


(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside caro during a last illness from disease unrelated to any form of injury.


(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed. -


(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


A R-301


OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


(City or Town)


1 PLACE OF DEATH


County


City or Town ..


Manthropo


No ..


10.


Cora Sp


State


Mass


Registered No.


16.5


St ...


Ward


(If death occurred in a hospital or institution, give its NAME instead of street and number)


thancis


Q/ Bussière


(If in the Army or Navy of the United States, give rank, organization, etc.)


(a) Residence.


No.


10 bara St


.St.


Ward.


(If non-resident give city or town and State)


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


3 SEX-


Homale Heute


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


Married


5a If married, widowed, pr divorced


HUSBAND of


(or) WIFE of


L'Bussière


6 DATE OF BIRTH.


Cannot be learned


( Month)


(Day)


(Year)


7 AGE


Years


28


Months


Days


If LESS than


1 day ......... hrs.


pr ....... min.


If STILLBORN, enter that fact here


8 OCCUPATION OF DECEASED


(a) Trade, profession, or


particular kind of work


Housewife


(h) Name of employer


Washington


9 BIRTHPLACE (City)


(State or country)


IDC.


10 NAME OF


FATHER


John


11 BIRTHPLACE OF Cannot be learned FATHER (City) (State or country)


42.MAIDEN NAME


OF MOTHER


Cannot be learned


13 BIRTHPLACE OF MOTHER (City) (State or country)


Cannot be learned


14 John L. Bussière


Informant


(Address)


16 Cora St


15 Nov. 14: 1921


Filed (Month) (Day) (Year)


REGISTRAR


21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued


S.h. Mowy


Official Health Officer position!


Date of


11/3/2/


Permit


No. 3/50


0,000


in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See should be carerdfly supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH .....


instructions and extracts from the laws on back of certificate.


PARENTS


Was there an autopsy ?


NO


What test confirmed diagnosis ?


(Signed)


Horace & Soule


, M.D.


( Address).


180 Wonttrop 21 Walterop


1928


Morambu


( Month)


(Day)


(Year)


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


Windlicht Monthago


DATE OF BURIAL Av. 3/21


(Cemetery)


(City or town)


20 UNDERTAKER


ADDRESS


J. O'malley Virtual


.


mos.


.ds.


CONTRIBUTORY


Phlegmasia alba Dolens


(SECONDARY)


Probably 3 weeks


.. (duration)


yrs ........


mos.


ds.


18 Where was disease contracted


if not at place of death ?


Did an operation precede death ?


NO


Date of


that I last saw her


alive on


Oct 29


19.21


and that death occurred, on the date stated above, at.


m.


The CAUSE OF DEATH was as follows :


Pulmonary embolism


.


following chuldbuilt


(Year)


17


I HEREBY CERTIFY, That I attended deceased from


21


to.


to Oct29


19 21


....


Oct 10


19


Oct


31


(Day)


1921


16 DATE OF DEATH


(Month)


MEDICAL CERTIFICATE OF DEATH


4 COLOR OR RACE


2 FULL NAME


(Usual place of abode)


(duration)


yrs ...


ILATE OF DEATH


LApproved by U. S. Census and American Public Health Association]


Statement of occupation. - Precise statement of occupation 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 he sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stationary fireman, etc. Butin 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 he used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Lahorer," "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 house- hold only (not paid Housekeepers who receive a definite salary), may he entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should he 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 he indicated 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: Cere- brospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualifiec, is indefinite); Tuberculosis of lungs, men- inges, peritoneum, 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 .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Dehility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can he ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.




Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.