Town of Winthrop : Record of Deaths 1919-1921, Part 6

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 6


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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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: Cerc- brospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never rsport "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualified, is indsfinite); Tuberculosis of lungs, men- inges, peritoneum, etc., Carcinoma, Sarcoma, etc., of .......... (name origin; "Cancer" is less dsfinits; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. Ths 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," "Ansmia" (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 diseasss resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.


State cause for which surgical operation was undertaken.


(Recommendations on statsment 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.


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 standard 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 dicd [defined so that it can bs 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. . . . - Reviscd 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 disd; . . . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written statement con- taining the facts required by law to be returned and recorded, which ... shall be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in lisu thereof a certifi- cate 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, 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 person to whom the per- mit 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 clark or to the city registrar in the place where the deceased died, his name and rssidsnce, 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 practics:


(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 disd without recent medical attendance or whose physician is absent from home when the certificate of death is necded.


(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 dissase resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1919.


CITY OF BOSTON


FULL NAME


FRANK ALDEN


Registered No.


1540


Place of Death


Boston


Date of Death


JAN.27


1919,


Age


57


years


months days


STATISTICAL DETAILS.


SEX


COLOR


SINGLE, MARRIED, WID., DIV.


M


W


M


Maiden Name


Husband's Name


Birthplace


VINEYARD HAVEN


Name of Father


JOHN ALDEN


Birthplace of Father MIDDLEBORO


Maiden Name of Mother


HEPSEY PEASE


Birthplace of Mother VINEYARD HAVEN


(Signed)


E.P.HOWARD M.D.


1919


SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.


Place of Burial or removal


WINTHROP


Undertaker C.R.BENNISON


Date of Burial


WINTHROP


Usual


Residence


WINTHROP (22 HARVARD ST)


Filed


JAN.30


1919.


A true copy.


Attest :


EumSeinen


Registrar.


MARGIN RESERVED FOR BINDING.


PHYSICIAN'S CERTIFICATE.


1919, I HEREBY CERTIFY that I attended deceased during last illness from 1919, to that to the best of my knowledge and belief death occurred, on the date stated above, and that the CAUSE OF DEATH was as follows:


R


A A


Is Primary


R


8.0B18


SOFFICE


BOSTONIA CONDITA A


4. 1822


1650.


GIMINE DONATA D


STON.


MASS.


Contributory : (Duration )


ACUTE PERITONITIS-DAYS


CITY


( AUTOPSY )


CARCINOMA STOMACH -1 MONTH


Occupation


WATCHMAN


Informant


PETER BENT BRIGHAM HOSPT .


Jan. 27, 1919


Form R-302


The Commamuralth of Massachusetts


MEDICAL EXAMINER'S CERTIFICATE OF DEATH


OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS


1 PLACE OF DEATH


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


County


Suffolk


State


mass


Registered No ..


City or Town


Winthrop


.. 1


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


Ward


2 FULL NAME.


angus Mac Donald


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


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


male


4 COLOR OR RACE


White


5 SINSLE, MARRIED, WIDOWED, OR


DAVORCED (writgthe word)


Single


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


6 DATE OF BIRTH


(Month)


('Day)


(Year)


7 AGE


Years


Months


Days


If LESS than


1 day ........ brs.


or ....... min.


If STILLBORN, enter that fact here


8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work (b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer


Silverplated.


Waltham


9 BIRTHPLACE (City)


(State or country)


mass.


10 NAME OF


FATHER


James ?


PARENTS


11 BIRTHPLACE OF


FATHER (City)


(State or country) Nova Scotia


12 MAIDEN NAME


margaret Normal


OF MOTHER


13 BIRTHPLACE OF


MOTHER (City)


Ochener goch.


(State or country)


14 Sarah Holland.


Informant


(Address)


100 manhall St Machen


15


Filed ..


(Month) (Day) (Year)


REGISTRAR


21 Burial permit


issued by


Official position


MEDICAL CERTIFICATE OF DEATH


Four Paws


28


(Day)


1919


(Year)


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 :


asphyxiation by drowning.


Presumably accidental.


7


(Scc reverse side for additional spacc)


18 Where was injury sustained


if not at place of death?


(Signed)


W 8 Watters


M.D.


(Address)


80E. Concord St


Medical Examiner for


Suffolk County


Date


4, au. 29.


1919


( Yeary


(Month)


(Day)


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


Calvary Waltham


20 UNDERTAKER


John + Oj maley


22 Date of issue


DATE OF BURIAL


/ 29 1919


(Month) (Day) (Year)


ADDRESS


Winthrop


See reverse side for extracts from the laws relative to the return of certificates of death. DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important.


should be carefully supplied. AGE should be stated EXACTLY. MEDICAL EXAMINERS should state CAUSE OF


MARGIN RESERVED FOR BINDING N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information 0- 10. 10,000.


9243


Ingleside PR Playground St.


(a) Residence. No. Ao marshalli St.


(Usnal place of abode)


16 DATE OF DEATH


(AI onth)


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 seen 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 elerk 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 statement containing the facts required by law to be returned 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 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, 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 vio- lence, the medical examiner only shall make such certificate. . . . The person 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 infor- mation which can be obtained as to the deceased, or as to the manner or eause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.


Medieal examiners shall, in all cases, certify to the city or town elcrk 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 sup- posed 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 duting 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 discase 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 injury 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


For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine 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) should also be stated.


DESCRIPTION (for unknown person)


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


Jan. 28, 1919


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


(City or town)


A


1 PLACE OF DEATH


County


State


Registered No .....


Township


or Village


.or


No. 5%,


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


2 FULL NAME Elheren


Galina


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


Ward.


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


months days


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


Chile


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


5a If married, widowed, or divorced HUSBAND of (or) WIFE of


6 DATE OF BIRTH (month, day, and year)


7 AGE


Years


Months


Days


If LESS than 1 day, ........ hrs. or ........ min.


8 OCCUPATION OF DECEASED


(a) Trade, profession, or particular kind of work /1.04


(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer


9 BIRTHPLACE (city or town)


(State or country)


10 NAME OF FATHER HER Michael Jahin


PARENTS


11 BIRTHPLACE OF FATHER (city of town)


(State or country)


12 MAIDEN NAME OF MOTHERE Chemme Hanne


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


14


Informant


(Address)


15 Filed 2-31 19


U


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH (month, day, and year) ( an ) c 19/2


17 I HEREBY CERTIFY, That I attended deceased from 50 1919, to 7 30 19.17.


-


that I last saw h . alive on


30


, 19 19 17


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


10.300 m.


The CAUSE OF DEATH* was as follows:


Cardiac dilatation


(acute)


(duration)


yrs.


mos.


/2 ds.


CONTRIBUTORY


Double Mitral Cesion


(SECONDARY)


(duration)


20


.yrs.


mos.


ds.


18 Where was disease contracted


if not at place of death ?


Did an operation precede death?


Date of


/


Was there an autopsy ?


1


What test confirmed diagnosis?


(Signed)


M.D.


1/3/19/9 (Address) 362 Shaben So Will


* 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


1919


20 UNDERTAKER


Yes.


ADDRESS


$0.201.1


MARGIN RESERVED FOR BINDING


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.


City


Ward


(a) Residence. No .. (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


102


13


YISED UNITED SIP DIATES 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 healthifulness 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 enginecr, 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," etc., without more precise specification, as- Day laborer, Farm laborer, Laborer -Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.


Statement of cause of death .- 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, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 Gs .; Broneho- pneumonia (secondary), 10 ds. Never report mere syinp- 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,""Tremia," ," "Inanition," "Maras- mus," "Old age," "Shock," "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; 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 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 .- 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.


14


Informant


(Address)


726 Santos


86 Boston


15


File Jeb. 10., 1919.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


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


19 19


3 SEX


F


4 COLOR OR RACE


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


W-


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


Zom L. Sweeney


6 DATE OF BIRTH (month, day, and Fear) Nov. 1301854


7 AGE


Years


64


Months


2


Days


19


If LESS than


The CAUSE OF DEATH* was as follows :


1 day, ........ hrs. or ........ min. Chrome Endo carditis


1


8 OCCUPATION OF DECEASED


(a) Trade, profession, or


particular kind of work


at Home


. (duration)


3


yrs.


.. mos ..


ds.


CONTRIBUTORY


Cliente articular


Rheumat


(duration)


2


mos.


ds.


............... yrs ...


9 BIRTHPLACE (city or tout


6. Boston


(Statc or country)


mare


10 NAME OF FATHER


George & Shimmer


11 BIRTHPLACE OF FATHER (city or town


(State or country)


une


12 MAIDEN NAME OF MOTHERSauch E. Hanlay


13 BIRTHPLACE OF MOTHER (city or town)


(State or country)


Lass,


Salen


* 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


Harmony Grove i'm


Salem


DATE OF BURIAL


Feb2/ 2019


20 UNDERTAKER


O.g. Rolling


ADDRESS


6. Boatin


MARGIN RESERVED FOR BINDING


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


....


(City or town)


1 PLACE OF DEATH


County


- 4


State


mare


Registered No .....


Township


City


No. 40


,


or Ville


River Road


St.,


Ward


or


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


2 FULL NAME


Fannie K. Sweeney


(a) Residence.


No ..


40 Riverroad &


St.,


Ward.


(Usual place of abod. . )


Leogtb of residence io city or town where death occorred


-


years


months -


days.


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


years


mooths


days


17


I HEREBY CERTIFY, That I attended deceased from


Out


1


19 18, to


Fib


,19 ... 19


that I last saw h


alive on


Feb


1


19 .. ₺ 9.


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


SP


m.


18 Where was disease contracted


if not at place of death ?


Did an operation precede death ? ho


Date of ..


Was there an autopsy ?


ho


What test confirmed diagnosis ?


Sounds-Inlayment


I.I.D.


Fil 2 1919


dress) 726 Saralaya Sp


(Signed) .....


Portland


PARENTS


(b) Generaloature of industry, bosiness, or establishmeot in which employed (or employer) (c) Name of employer


-


PERSONAL AND STATISTICAL PARTICULARS


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


REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthifulness 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- ilor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, ete. 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,"




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