Town of Winthrop : Record of Deaths 1919-1921, Part 56

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 56


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).


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12 MAIDEN NAME OF MOTHER Martha tealle


13 BIRTHPLACE OF MOTHER (city of town Portland (State or country)


14 MLemuel G. Moody


Informant


(Addr 265 Pleasant St


15


Filed Oct. 21, 1919


REGISTRAR


16 DATE OF DEATH (month, day, and year) out 157 19 /1


17


I HEREBY CERTIFY, That I attended deceased from


,


Sept 20"


, 19 19


ut 1st


19 19


to


that I last saw h. M. alive on .....


at 14


19.19.


3 30 pm and that death occurred, on the date stated above, at


The CAUSE OF DEATH* was as follows :


If LESS than 1 day, ....... hrs. or ........ min. Chronic Interstitial nothing ,


chimica artiso -selundso


(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 ?


W Date of


Was there an autopsy ?.


What test confirmed diagnosis ?


(Signed)


, 19 (Address)


auf 16 /19 Pintural


* 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


Fevergeen Gen.


Portland


DATE OF BURIAL manelet. 161919


20 UNDERTAKER


ADDRESS


of certificate.


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,


State


Registered No.


or


City


(a) Residence.


No. 265 Pleasant


(Usual place of abode)


PARENTS


MEDICAL CERTIFICATE OF DEATH


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


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architeet, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ctc. 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 .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the saine disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fcver (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,"


" Col- "Anemia" (merely symptomatic), "Atrophy,"


lapse," "Coma,"


a" "Convulsions,"" "Debility"


("Con-


genital," "Senile." etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock,"" "Uremia," "Wcakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or iniscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State cause for which surgical operation was undertaken. For VIOLENT DEATIIS 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 Cominittee 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.


1


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


Winthrop


(City or town)


1 PLACE OF DEATH


County.


Suffolka


Township


Minthade


or Village. No. 117, Herman


St., Ward


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


2 FULL NAME Mam Faloner leanter


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


(a) Residence.


No. 1117 Paman


(Usual place of abode) Length of residence io city or towo where death occurred years mooths -


days.


How long in U. S., if of foreigo birth ?


years


months


days


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


Jemale While


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


married


5a If married, widowed, or divorced HUSBAND of (or) WIFE of Les lis le anter


6 DATE OF BIRTH (month, day, and year) y. 6.1873


7 AGE


Years


4.5


Months


11


Days


13


8 OCCUPATION OF DECEASED


at Home


9 BIRTHPLACE (city or town)


Newark


(State or country) 2.2


10 NAME OF FATHER William Campbell


11 BIRTHPLACE OF FATHER (city or town). Ilbegon (State or country) Scotland.


12 MAIDEN NAME OF MOTHER Man Julcomer


13 BIRTHPLACE OF MOTHER (city or town) ...


(State or country)


Seste Tutul


14 Mr. Leslie P. Carter


Info


(Address) 117 Aleman St.


Filed. Oct. 21, 1919.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH (month, day, and year) Det. 14 19


19


17 I HEREBY CERTIFY, That I attended deceased from art 14 19/9, to art 14 1919


that I last saw h.f .......


alive on


oct 1 3ª


1914


and that death occurred, on the date stated above, at 4150 .m. The CAUSE OF DEATH* was as follows :


If LESS than 1 day, ........ hrs. or ........ min. Chronic alestitial sephritis


arTino schermo


(duration)


2


mos.


ds.


CONTRIBUTORY


unaemig


(SECONDARY)


(duration)


... yrs.


........... mos.


ds.


18 Where was disease contracted


if not at place of death ?


Did an operation precede death? 100 Date of.


Was there an autopsy ?.


Ejam. 1 urine


What test confirmed diagnosis ?


(Signed)


, 19


( Address)


170 unthorpeftworthit


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. (Sec reverse side for additional space.)


19 PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL Teambridge Cemeter, Pct /19/9


ADDRESS


20 UNDERTAKER le R. Bennison


City. (a) Trade. profession, or particular kind of work PARENTS carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, of certificate. so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back 15 N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (b) General nature of industry, basicess, or establishment io which employed (or employer) (c) Name of employer


mass State


Registered No.


or


St., Ward.


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


yrs ..


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


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive cngincer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) 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 laborcr, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilousckccpers 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- eifically 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 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; 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 mere symp- toms or terminal conditions, such as "Asthenia,"


"Col- "Anemia" (merely symptomatic), "Atrophy," lapse," "Coma," "Convulsions,"' "Debility" ("Con-


genital," "Senile." ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," ete., 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," ete. State cause for which surgical operation was undertaken. For VIOLENT DEATIIS 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; Poisoncd 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 Commuee 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.


The Commonwealth of Massachusetts


CERTIFICATE OF DEATH OF NON-RESIDENT


( City or town)


1 PLACE OF DEATH


County


Worcester


State


Mass


Registered No.


(Place of residence)


St.,


Ward


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


2 FULL NAME


Frederick I Hardenbergh


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


(a) Residence. State


Mass


City or Town


Winthrop


No.


88 Circuit Rd .-


St."


(Usual place of abode)


Length of resideoce io city or town where death occurred


years


3


months


days


How long in U. S., if of foreigo birth?


years


mooths


days


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


Male


4 COLOR OR RACE


white


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


single


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


6 DATE OF BIRTH (month, day, and year) Mar 3 1872


7 AGE


47


l'ears


7


Months


19


Days


Mf LESS thao


I day ......... hrs.


or ....... min.


Hf STILLBORN, eoter that fact bere


8 OCCUPATION OF DECEASED


(a) Trade, profession, or


salesman


particular kiod of work


(b) General nature of industry,


business, or establishment in


which employed (or employer)


(c) Name of employer


unknown


.(duration).


........ yrs ................. mos ................. ds.


9 BIRTHPLACE (city or town)


Omaha, Neb.


(State or country)


CONTRIBUTORY


(SECONDARY)


(duration)


...... yrs. ........... mos. ..............


. ds.


10 NAME OF FATHER


Jacob R


18 Where was disease contracted


if not at place of death ?


unknown


11 BIRTHPLACE OF FATHER (city or town).


(State or country)


unable to learn


no


12 MAIDEN NAME OF MOTHER


Elizabeth Stetsdinwhat test confirmed diagnosis?


(Sigoed) .... . . I . Mountford


M.D.


14 Hospital records


Informant


(Address)


Worcester


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


New brunswick


: J


DATE OF BURIAL


Oct 2019 19


15 Oct 29 Filed


19


Registrar of city or towo where death occurred Filed nov.5 1919 Eulalie Churchill


out Registrar of city or towo where deceased resided ....


20 UNDERTAKER Geo Sessions Sons Co


ADDRESS


ircest er


N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be 80 that it may be properly classified. Exact statoment 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.


PARENTS


Did an operation precede death?


no


Date of


Was there an autopsy?


Basserman


13 BIRTHPLACE OF MOTHER (city or town)


(State or country)


Unable to learn


De 3. 1919


. 19- ( Address)


worcester


22


19


19


that I last saw h.


on


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


8.40p


.... m.


The CAUSE OF DEATH" was as follows :


* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (I) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)


General paresis of the insane.


worcester


Registered No


(Place of death)


City or Town


Worcester


No. worcester State Hospital


16 DATE OF DEATH (month, day, and year)


Oct 22


19


10


17


HEREBY CERTIFY, That I attended deceased from


I


Oct 22


19


19


July 22


19


...


to


19


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 ean 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, 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) Colton 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,"


"Forcınan," "Manager," "Dealer," ete., 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- eifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the oceupation 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 saine 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- toncum, ete., 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: Measles (discase causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report inere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," " Col-


(“Con- lapse," "Coma," "Convulsions,"""Debility" genital," "Senile." ete.),


" Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," ete., when a definite disease ean be ascertained as the cause. Always qualify all discases resulting from ehild- 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 suchi, 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 deatlis 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 onc supposed to bc due to Alcoholism, etc.


4. Deaths under eireumstances unknown, as A person found dead, etc.


ADDITIONAL SPACE


FOR FURTHER STATEMENTS BY


PHYSICIAN.


R 303. 6-'18. 50,000.


Township City. 2. FULL NAME 3 SEX 7 AGE Years particular kind of work PARENTS of certificate. 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 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


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


(City or town)


1 PLACE OF DEATH


County.


Suffolk


State


Registered No ..


or Village.


.. or


No.


17 Taffsave.


St.,


.Ward


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


Mary


Elizabeth


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


(a) Residence. No. 27 Taf the cure St., .Ward.


(Usual place of abode)


Length of residence in city or town where death occurred


X


years


6 months


X


days.


How long in U. S., if of foreign birth ?


years


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


months


days


PERSONAL AND STATISTICAL PARTICULARS


4 COLOR OR RACE


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


widern


-


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


wider David Sich


6 DATE OF BIRTH (month, day, and year) July 4: 1841


Months


3


Days


21


If LESS than I day, ........ hrs. or ....... min.


8 OCCUPATION OF DECEASED


(a) Trade. profession, or


at Home


9 BIRTHPLACE (city or town).


Suite


(State or country) mar


10 NAME OF FATHER


3. Canpled


11 BIRTHPLACE OF FATHER (city or town) Calle (State or country)


12 MAIDEN NAME OF MOTHER ER Elizabete Brown 0/26, 19


13 BIRTHPLACE OF MOTHER (city or town) ...


(State or country)


14 Celler & Smith


Informant


(Address Som) Mitcha Var # 17


15 Oct. 28, 1919


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH (month, day, and year) Och. 25. 19/6.


17


I HEREBY CERTIFY, That I attended deceased from


Och


15


1919, to.


Och. 20:


1919.


that I last saw her alive on


Oct. It.


, 1919.


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


m. The CAUSE OF DEATH* was as follows :


(duration)


.yrs ............... mos.


ds.


CONTRIBUTORY


autores- silence


(SECONDARY


(duration)


.... yrs.


18 Where was disease contracted


if not at place of death ?


Did an operation precede death?


200. Date of


-


Was there an autopsy ?


What test confirmed diagnosis ?


Ofer and.


.


(Signed)


Villique & Pantes


M.D.


(Address)


* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (Sce reverse side for additional space.)


DATE OF BURIAL


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


Whiting sville hewn


19 /9


20 UNDERTAKER


ADDRESS


..........


mos.


ds.


frick


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


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the 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 sehool or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.




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