USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1922-1924 > Part 138
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 | Part 213 | Part 214 | Part 215 | Part 216 | Part 217 | Part 218 | Part 219 | Part 220 | Part 221 | Part 222 | Part 223 | Part 224 | Part 225 | Part 226 | Part 227 | Part 228 | Part 229
Stella Pique
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
(Usual place of abode)
Length of residance in city or town whera death occurred
years
months
days.
Now long in U. S., if of foreign birth?
years
months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
December 10-1923
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY, That I attended deceased from
July 1et
1943_, to
2080.10
192 3,
that I last saw her
alive on
Lese.10
19.2.3
and that death occurred, on the date stated above, at
7 p.m.
The CAUSE OF DEATH was as follows:
Diabetes Mellitus
(duration)
2
_yrs.
_mos.
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
_yrs.
3
ds
17 Where was disease contracted
if not at place of death?
Did an operation precede death ?.
No
Date of
Was there an autopsy ?.
No
What test confinmed diagnosis?
O
(Address)
(Signed)
687 Winther of ane
Data
Le ecomber 11h 1943 (Year)
(Month)
(Day)
18 PLACE OF |BURIAL, CREMATION DR REMOVAL
Winthrop
Winthrop
(Cemetery)
(City or town)
DATE OF BURIAL Dec. 13. 1923
ADDRESS
withrop.s
20 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued.
00.000
2 FULL NAME
3 SEX
+imake
(
6 AGE
Years
63.
PARENTS
13
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
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
Filed
N. D .- WRITE PLAINLY, WITH UNTADING DLAUN INA THIS IS APERMANENT RECORD. Every Item or formation
(State or country)
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, DR
DIVORCED (write the word)
Married.
5a If married, widowed or divorced
HUSBAND of
(or) WIFE of
Lucius G. SPEEre.
Months
5
Days
14
If LESS than 1 day .___ hrs. ௦ __ min.
If STILLBORN, anter that fact here
-.
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Nama of employer
Pit nome.
8 BIRTHPLACE (City)
Cantón
(State or country)
ME
9 NAME OF
FATHER
Edward - Chill
10 BIRTHPLACE OF
FATHER (City)
11 MAIDEN NAME
OF MOTHER
Melisa Faire
12 BIRTHPLACE OF
MOTHER (City)
Campden mè
(State or country)
Informant
Nurtue. M. Vierrio
(Address)
117 Humbert Store Qui
14 Dec 13/23
(Month)
(Day) (Year)
REGISTRAR
19 UNDERTAKER
G. R. Pensión.
Official position_
Health' offices
Date of issue of permit 12/12/23
Permit ND. 658
117 Winthrop & Drive
Lore Str ,
Ward.
(If non-resident give city or town and state)
Diabetic Coma
decr 10 19 923
REVISED UNITED STATES 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 pursuite can be known. The question applies to each and every person, irre- spective of age. For many occupatione a eingle word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Com- positor, Architect, Locomotive engineer, Civil engineer, Stationary fire- man, 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 businese or industry, and therefore an additional line is provided for the latter statement; it ehould 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," "Fore- man," "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 House- wife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report specifically the occupatione of persone engaged in domestic service for wages, ae Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, etate occupa- tion at beginning of illness. If retired from bueiness, 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 eame accepted term for the eame disease. Exam- ples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitie"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneu- monia; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma, etc., of . . (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasme); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or intercurrent) affection need not be stated unlese important. Example: Measles (disease caueing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptome or terminal conditions, euch ae "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convul- sions," "Debility" ("Congenital," "Senile," etc.), "Dropey," "Ex- haustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mue," "Old age," "Shock," "Uremia,". "Weakness," etc., when a definite disease can be ascertained as the eause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUERPERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendatione on etatement of cause of death approved by Com- mittee on Nomenclature of the American Medical Aeeociation.)
Bronchopneumonia: If primary cause, write the word "primary"; 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, miscarriage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth- with, after the death of a person whom he has attended during his laet illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registra- tion a standard certificate of death, stating to the best of hie knowl- edge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required by section one, where same was contracted, the duration of his laet 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 ehall 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 pereon died ;. . . 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 ehall be accompanied, in case of an original interment, by a eatiefactory 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 pur- pose, or is insufficient, a physician 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 certificate. .. The person to whom the permit is so given and the physician certifying 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 re- quire .- Gen. Laws, Chap. 114, Sec. 45.
Medical examiners shall make examination upon the view of the dead bodies of only euch 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 place where the deceased died his name and residence, if known; otherwise a description as full as may be, with the cause and manner of death .- Gen. Laws, Chap. 38, Sec. 7.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the obeervance of the following rules of practice:
(1) Attending physicians will certify to such deaths only ae thoee of persone to whom they have given bedside care during a last illnese 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 unre- lated to any form of injury, have died without recent medical at- tendance or whoee physician is abeent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deathe supposably due to injury. These include not only deaths caused directly or indirectly by traumatiem (including reeulting septicemia), and by the action of chemical (drugs or poisone), thermal, or electrical agents, and deathe following abortion, but aleo deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of pereons found dead.
R-301 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Winthropo
1 PLACE OF DEATH
County
Swithhop
Suffolk
State
Mars.
(Gity or town)
Registered No.
Ward
2 FULL NAME
Doncus.
(If death occurred in a hospital or institution, give its NAME instead of street and number) Praman
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
years
3 months
days.
How long in U. S., if of foreign birth?
50
years
(If non-resident give city or town and state)
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIEO, WIDOWED, OR
DIVORCED (write the word)
Securities 10
1923
(Day)
(Year)
Sa If married, widowed or divorced
HUSBAND of
(or) WIFE of
6 AGE
Years
78
Months
11
Days
20
If LESS than
1 day ._ hrs.
or __ min.
If STILLBORN, anter that fact here
7 OCCUPATION OF DECEASED
(a) Trada, profession, or
particular kind of work
(b) Nama of employer
-
Rua (duration)
_yrs .____ mos.ds.
Celétio - seberesis
8 BIRTHPLACE (City)
(State or country)
Polmon mille
M. B.
9 NAME OF
FATHER
Edimond. Babcock
10 BIRTHPLACE OF
FATHER (City)
(State or country)
3. 13.
12 BIRTHPLACE OF
MOTHER (City)
(State or country)
n. B.
17 Where was disease contracted
if not at place of death?
Did an operation precede death?
200
Date of.
Was there an autopsy?
200
What test confirmed diagnosis?
Clinical
(Signed)
(Address),
123 Hermetich ST Winberg
11
6 1423 Place
Date
(Month)
(Day)
(Year)
18 PLACE OF BURIAL, CREMATION OR REMOVAL
· DATE OF BURIAL Conver Sackville
(Cemetery)
(City or town) LB.
14 Dec, 13. 1933
Filed
(Month) (Day) (Year)
REGISTRAR
19 UNDERTAKER
C.R. Bennison
ADDRESS
L
20 : HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued L.C.Daniele
Official position wealth Officer
Date df issue of permit 12/12/23
Permit NO. 6.57
00000
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 should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
PARENTS
13 B.J. Jeunon
Informant
(Address)
8 vini ana
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
(Month)
16
I HEREBY CERTIFY, That I attended deceased from
3
1923, to
Que 10
1923
that I last saw her alive on
, 19 23,
and that death occurred, on the date stated above, at
3 3000 m.
The CAUSE OF DEATH was as follows:
CONTRIBUTORY
(SECONDARY)
que(duration)
yrs __ mos .= >_
ds
11 MAIDEN NAME
OF MOTHER
M. O.
$
No ..
8. .
Vine Goennist.
City or Town
I Vine avz
St.,
Ward.
Dec 10 1923 REVISED UNITED STATES 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, irre- spective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Com- positor, Architect, Locomotive engineer, Civil engineer, Stationary fire- man, 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," "Fore- man," "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 House- wife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupa- tion 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. Exam- ples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneu- monia; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, meninges, 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 intercurrent) 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," "Collapse," "Coma," "Convul- sions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Ex- haustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia,". "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUERPERAL 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 "primary"; 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, miscarriage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth- with, 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 registra- tion a standard certificate of death, stating to the best of his knowl- edge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required by section one, where same was contracted, 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 died ;. .. 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, in case of an original interment, 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 pur- pose, or is insufficient, a physician 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 certificate. . . The person to whom the permit is so given and the physician certifying 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 re- quire .- Gen. Laws, Chap. 114, Sec. 45.
Medical examiners shall make examination 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 place where the deceased died his name and residence, if known; otherwise a description as full as may be, with the cause 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 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 unre- lated to any form of injury, have died without recent medical at- tendance 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.
I R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Winthrop. hrob
I PLACE OF DEATH
County
Winthrop
State Mars.
(City or town)
Registered No.
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number) Ulampen.
2 FULL NAME
12 (heater C'est.
Ward.
(If non-resident give city or town and state)
Length of residence in city or town where death occurrad
25
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, MARRIEO, WIDOWED, OR
DIVORCEO (write the word)
Wilown
5a If married, widowed or divorced
HUSBAND of
(or) WIFE of
of fame
6 AGE
Years
90
Months 3
Days
20
If LESS than 1 day ._ hrs. or ___ min.
If STILLBORN, anter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
ED Recent B.RBX
(b) Nama of employer
Boas C argument L. Rail Road
8 BIRTHPLACE (City)
(State or country)
21.13.
9 NAME OF
FATHER
David. Ramsey
PARENTS
(State or country)
London derry Horch fre
11 MAIDEN NAME
OF MOTHER
Rebecka. Calhoun
12 BIRTHPLACE OF
MOTHER (City)
melina
(State or country)
Londonderry Hout Feel
13
Informant
Fred. M. Ramsey
(Address)
14 Dec, 13 1923
Filed
(Month) (Day) (Year)
REGISTRAR
19 UNDERTAKER
2. R. Jameson
ADDRESS
20 1 HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with ma- BEFORE the burial or transit permit was issued L'-C Daniele
Official position
Health Officer
Date of ISSUB of permit 12/2/23 Permit NO 667
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 should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH ......
00.000
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY, That I attended deceased from
aferie
19Z /, to
1923.
that I last saw h
un alive on
19
23
and that death occurred, on the date stated above, at.
11 00
.m.
The CAUSE OF DEATH was as follows:
Cloud
(duration)
2 yrs. 6 mos. - ds.
CONTRIBUTORY
(SECONDARY)
(duration)
_yrs.
mos.
ds
17 Where was disease contracted
if not at place of death?
Did an operation precede death?
Date of
Was there an autopsy? 200
what test confirmed diagnosis?
Quelle E. Coliusar
., M. D.
(Signed)
(Address)
123 Vielen ST-
Data_
Sem-11 -1923
(Month)
(Day)
(Year)
18 PLACE OF BURIAL, CREMATION OR REMOVAL
W shoot
(Cemetery)
(City or town)
DATE OF BURIAL
Dec 13.23
No.
12
Chester Give
City or Town
John Mc
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
(Usual place of abode)
10
1423
10 BIRTHPLACE OF
FATHER (City)
Malone.
. 19 23
REVISED UNITED STATES 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, irre- spective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Com- positor, Architect, Locomotive engineer, Civil engineer, Stationary fire- man, 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 nasded. 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," "Fore- man," "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 House- wife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupa- tion 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, writs None.
Statement of cause of death .- Name, first, the nieEAGE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Exam- ples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneu- monia; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, meninges, 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 intercurrent) affsction 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," "Collapse," "Coma," "Convul- sions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Ex- haustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia,". "Weakness." etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUERPERAL 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.