USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1932 > Part 87
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year)
11. Total time Crears) spent Mitthis occupation
12. BIRTHPLACE (city or town)
(State or country)
13. NAME
14. BIRTHPLACE (city or town). (State or country)
15. MAIDEN NAME
16. BIRTHPLACE (city of town)raed
17. INFORMANT
(Address)
18. BURIAL, CREMATION, OR REMOVAL
Place
Date
19
19. UNDERTAKER.
(Address)
193
20. FILED .19
Registrar.
MEDICAL CERTIFICATE OF DEATH
22.
I HEREBY CERTIFY. That I attended deceased from
19
... to_
. 19.
--
I last saw h ______ alive on
__ , 19
-; death is sald
to haveoccurred on the date stated above, at ___ .m.
The principal cause of death and related causes of Importance werd as follows:
Dale of onse!
Followin partro intestinal/intoxication
"Other contributory causes of importance:
Mistral stenade.
un detine
Name of operation 2200
-Date of
What test confirmed diagnosis ?.
Was there an autopsyZ.
23. If death was due to external causes (violence) fill in also the following:
Accident, suicide, or homicide?
Date of injury.
19
Where did Injury occur ?.
(Specify city or town, county, and Stato)
Specify whethor Injury occurred In industry, In home, or In public place.
Manner of Injury
Nature of Injury
24. Was disease or Injury In any way related to occupation of deceased?
If so, specify
atlante aber
(Signed).
(Address)
c11-8184
=
"Registrar of City or Town where deceased resided)
(State or country)
MAR 3
OCCUPATION MOTHER OCCUPATION is very important. See instructions on back of certificate. state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of FATHER
or
UNITED STATES STANDARD CERTIFICATE OF DEATH
Statement of occupation .- Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the deceased had retired from business, report the occupation prior to retirement. Children not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housewife in answer to Question 8 and own home in answer to Question 9. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as servant-private family, cook-hotel, etc. For a person who had no occupation whatever write none.
To be complete, an occupation return must state:
8 .- The trade, profession, or particular kind of work done.
9 .- The industry or business in which the work was done.
10 .- The month and year the deceased last worked at the occupation. 11 .- The number of years the deceased followed the occupation.
In stating the occupation, avoid the use of such indefinite terms as "employee," "worker," "operative," etc. Find out the particular kind of work done and return that, as spinner, weaver, etc.
In stating the industry or business, avoid the use of such general terms as "store," "factory," "mill," etc. State the particular kind of store, factory, mill, etc., as grocery store, soap factory, cotton mill, etc.
Distinguish carefully the different kinds of engineers by stating the full descriptive titles, as civil engineer, mechanical engineer, mining engineer, stationary engineer, etc. Avoid the term "laborer" when a more precise statement of the occupation can be secured. Do not use the word "mechanic," but give the exact occupation, as carpenter, painter, machinist, etc. Distinguish carefully between retail merchants and wholesale merchants. A person who sells goods should be called a salesman and not a clerk.
Statement of cause of death .- Cause of death means the disease, injury, or complication which causes death, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease or injury causing death. As related causes, name earlier morbid conditions, if any, related to the principal cause and any important complication of the principal cause. Under other contributory causes of importance, name other important diseases or injuries. Examples:
Example I
Example II
The principal cause of death and related causes of importance were as follows:
Date of onsel
3. The principal cause of death and related causes
Date of ensel
of importance were as follows:
Arteriosclerosis
1915
Attack ofepilepsy
1 week ago
Chronic interstitial nephritis
1921
Run over .by street car
1 week ago
Cerebral hemorrhage
July5, 1927
Peritonitis
3 days ago
Other contributory causes of importance:
Other contributery causes of importance:
Gallstones
May 1, 1923
Gastroenteritis
1 year
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY PHYSICIAN
U. S. GOVERNMENT PRINTING OFFICE: 1930
c11-3184
223)
STANDARD CERTIFICATE OF DEATH
1. PLACE OF DEATH
County
Fresno
Township
7
11
City
LebendenHo.
or Village
or
Ward St.
(If death occurred in a hospital or institution, give ita NAME instead of street and number)
.mos. _____ ds. How long in U. S. If of foreign birth? _____ yrs. mos. ds.
2. FULL NAME
Helle M.
(a) Residence: No.
St.,
Winthrop maso
Maso
(If nonresident give city or town and State)
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
21. DATE OF DEATH (month, day, and roof
3/1932
, 19
22.
I HEREBY CERTIF
1932
Avthat I attended, deceased from
AUG
1932,
19
.,
to.
19.
Ba. If married widowed, or divorced
HUSBAND Of
(or) Carry. m. Ban
AUG
; death Is said
H fast saw h
alive on
6. DATE OF BIRTH (month, an), addome
-1820
7. AGE
61
Years
Months
7
Days
If LESS than
1 day, _____ hrs.
9 ---- min.
8. Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
9. Industry or business in which work was done, as silk mill, Saw mill, bank, etc.
10. Date deceased last worked at
this occupation (month and
year).
11. Total time (years)
spent In this
occupation
Other contributory causes of importance:
Name of operation
Date of
What test confirmed diagnosis ?.
Was there an autopsy ?.
23. If death was due to external causes (violence) fill in also the following:
Accident, suicide, or homicide?
Date of injury.
19
Where did injury occur ?.
(Specify city or town, county, and State)
Specify whether injury occurred In industry, in home, or In public place.
Manner of Injury
Nature of Injury
Was disease or Injury In any way ryated to occupation of deceased?
19. UNDERTAKER 24 Vill Aural man (Address) Selma caly
If so, specify (Signed) (Address)
MAR 3 1933
Date of onset
di Pectoris Ingena Declaro
Up
12. BIRTHPLACE (city or town)
(State or country)
14. BIRTHPLACE (chy er towr). (State or copy) Calland
MOTHER
15. MAIDE NAVE2 Clear
16. BIRTHPLACE (city cr town) (State or country) Scurtand
17. INFORlexmachanaldy
(Address) Selma cale
18, butAs, CREMATION, OR BEMOVAL Parchiabo maso Dat
lug 2, 123
V. S. No. 98
c 11-10931 OCCUPATION OCCUPATION is very important. See instructions on back of certificate. state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of FATHER
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
2377
State
Calil
Registered No,
3
Length of residence in city or town where death occurred
__ yrs.
Dango
(Usual place of abode)
28
4. COLOR OR RACES. SINGLE, MARRIED. WIDOWED.
1930
to have occurred on the date stated above, at. m.
The principal cause of death and related causes of Importance were as follows:
(Registrar of City or Town where deceased resided)
UNITED STATES STANDARD CERTIFICATE OF DEATH
Statement of occupation .- Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the deceased had retired from business, report the occupation prior to retirement. Children not gainfully employed may be returned as at school or at home. For a woinan whose only occupation was that of home housework, write housewife in answer to Question 8 and own home in answer to Question 9. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as servant-private family, cook-hotel, etc. For a person who had no occupation whatever write none. To be complete, an occupation return must state:
8 .- The trade, profession, or particular kind of work done.
9 .- The industry or business in which the work was done.
10 .- The month and year the deceased last worked at the occupation.
11 .- The number of years the deceased followed the occupation.
In stating the occupation, avoid the use of such indefinite terms as "employec," "worker," "operative," etc. Find out the particular kind of work done and return that, as spinner, weaver, etc.
In stating the industry or business, avoid the use of such general terms as "store," "factory," "mill," etc. State the particular kind of store, factory, mill, etc., as grocery store, soap factory, cotton mill, etc.
Distinguish carefully the different kinds of engineers by stating the full descriptive titles, as civil engineer, mechanical enginecr, mining engineer, stationary cngincer, etc. Avoid the term "laborer" when a more precise statement of the occupation can be secured. Do not use the word "mechanic," but give the exact occupation, as carpenter, painter, machinist, etc. Distinguish carefully between retail merchants and wholesale merchants. A person who sells goods should be called a salesman and not a clerk.
Statement of cause of death .- Cause of death means the disease, injury, or complication which causes death, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease or injury causing death. As related causes, name earlier morbid conditions, if any, related to the principal cause and any important complication of the principal cause. Under other contributory causes of importance, name other important diseases or injuries. Examples:
Example I
Example II
The principal cause of death and related causes of importance were as follows:
Date of onset
The principal cause of death and related causes of importance were as follows:
Date of onset
Arteriosclerosis
1915
Attack of epilepsy
1 week ago
Chronic interstitial nephritis
1921
Run over by street car
1 week ago
Cerebral hemorrhage
July 5, 1927
Peritonitis
3 days ago
Other contributory causes of importance: Gallstones
Other contributory causes of importance:
May 1, 1923
Gastroenteritis
1 year
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY PHYSICIAN
U. S. GOVERNMENT PRINTING OFTICE: 1030
c11- 3184
Fam 7 Diginal
1. PLACE OF DEATH: DIST. NO.
1054
PERMIT FOR REMOVAL AND BURIAL THIS IS NOT A DEATH CERTIFICATE
LOCAL REGISTERED NO. 523
CITY, TOWN OR
RURAL DISTRICT OF
Fresno
STREET AND NO
Ockenden, California
2. FULL NAME
NELLIE M. BANGS
IF DEATH OCCURRED IN HOSPITAL OR INSTITUTION, GIVE ITS NAME
RESIDENCE: NO ..
USUAL PLACE OF ABOOE
3. SEX
4. COLOR OR RACE| 5. SINGLE, MARRIED, WIDOWED OR
DIVORCED? (WRITE THE WORO)
married
22. DATE OF DEATH.
July
31
1932
MONTH
DAY
YEAR
5A. IF MARRIED, WIDOWED OR DIVORCED, NAME OF HUSBAND OR WIFE
Harry M. Bangs
6. DATE OF BIRTH.
Dec.
1870
MONTH
DAY
YEAR
7. AGE 61 YR .
7 MO ?
DAYS. ONE DAY.
HRS
.MIN
8. TRADE, PROFESSION OR KIND OF WORK DONE AS SPINNER, SAWYER, BOOKKEEPER, ETC ...
Housewife
9. INDUSTRY OR BUSINESS IN WHICH WORK WAS
DONE, AS SILKMILL, SAWMILL, BANK, ETC.
10. DATE DECEASED LAST WORKED AT
11. TOTAL YEARS SPENT
THIS OCCUPATION (MONTH AHO YEAR).
IN THIS OCCUPATION.
ON
AND THAT DEATH OCCURRED ON THE ABOVE STATED DATE AT THE HOUR OF
24. CORONER'S CERTIFICATE OF DEATH
I HEREBY CERTIFY, THAT I TOOK CHARGE OF THE REMAINS DESCRIBED ABOVE, HELD
AN Inquiry IHQUEST, AUTOPSY OR INQUIRY
THEREON, AND FROM SUCH ACTION FIND THAT SAID DECEASED CAME TO H. DEATH ON THE DATE STATED ABOVE.
THE PRINCIPAL CAUSE OF DEATH AND RELATED CAUSES OF IMPORTANCE, IN ORDER OF ONSET, WERE AS FOLLOWS:
DATE OF ONSET
Angina pectoris
OTHER CONTRIBUTORY CAUSES OF IMPORTANCE :
IF OPERATION, DATE OF.
WAS THERE
AN AUTOPSY ?.
CONDITION FOR WHICH PERFORMED. NAME LABORATORY TEST CONFIRMING DIAGNOSIS
A. CITY, TOWN OR RURAL
DISTRICT OF DEATH.
YRS.
.MOS.
1
DAYS
B. IN CALIFORNIA.
YRS.
5
.MOS.
DAYS
C. IN U.S. , IF OF
FOREIGN BIRTHLife
LYRS
MOS.
DAYS
18. INFORMANT (SIGNATURE).
Alex MacDonald
ADDRESSE. O. Box 593 Selma Calif
19. BURIAL, CREMATION OR REMOVAL ?.
Removal
PLACE
Winthrop Mass
WRITE THE WORO
DATE 8/2/3/2
INJURY.
26. IF DISEASE/ INJURY RELATED TO OCCUPATION, SPECIFY.
20. EMBALMER
LICENSE NO. SIGNATURE Luther Byrne
FUNERAL
DIRECTOR
Byrne Funeral Parlors
ADDRESS.
Selma, Calif.
21. FILED
OATE
LOCAL REGISTRAR
COUNTY OF
Fresno
LOCAL REGISTRAR'S PERMIT FOR REMOVAL
N. B .- THIS PERMIT CAN BE SIGNED ONLY BY THE LOCAL REGISTRAR ( DEPUTY OR SUBREGISTRAR) OF THE PRIMARY REGISTRATION DISTRICT IN WHICH THE DEATH OCCURRED AFTER THE FILING AND ACCEPTANCE OF A COMPLETE AND CORRECT CERTIFICATE OF DEATH LEGIBLY WRITTEN IN DURABLE BLACK INK. A CERTIFICATE OF DEATH HAVING BEEN PRESENTED TO ME, AND AFTER EXAMINATION THE SAME APPEARING TO BE COMPLETE, CORRECT AND SATIS- FACTORY AS REQUIRED BY LAW. I HAVE FILED IT WITH THE ABOVE STATED LOCAL REGISTERED NUMBER, AND ON THE BASIS THEREOF I HEREBY GRANT A PERMIT TO THE ABOVE NAMED UNDERTAKER FOR THE REMOVAL AND BURIAL OR CREMATION OF THE BODY OF SAID DECEASED PERSON AS STATED ABOVE. THE CASE OF DEATH FROM A DANGEROUS OR COMMUNICABLE DISEASE, THE BURIAL OR REMOVAL MUST BE CONDUCTED ACCORDING TO THE RULES OF THE STATE AND LOCAL BOARDS OF HEALTH.
DATED.
8-2- 19.32
BY n. Zahw
LOCAL REGISTRAR
THIS PERMIT IS SUFFICIENT FOR THE REMOVAL AND BURIAL OR CREMATION OF A BODY AT DESTINATION AS ABOVE INDICATED (SUBJECT TO LOCAL CEMETERY OR OTHER REGULATIONS) .
Endorsement of Sexton or Person in Charge of Premises on Which Interments or Cremations are Made
Sugli or Roberts Just
DATE OF INTERMENT OR CHEMYTION ISTRIKE OUT WORD NOT USED)
august. 10
_1932
PERSONIN CHARGE OF CEMETERY, BRUATORIUM, ETC. ) Winthrop Seventy Writers (NAME OF CEMTETY. CREMATORIUM, ETC ) nunes
ORIGINAL-TO FOLLOW THE BODY TO ITS DESTINATION-IF BURIAL OR CREMATION TAKES PLACE IN CALIFORNIA, THIS PERMIT MUST BE DELIVERED TO THE PERSON IN CHARGE OF THE CEMETERY OR CREMATORY BEFORE THE BODY IS BURIED OR CREMATED. THE PERSON IN CHARGE MUST RETURN IT. PROPERLY FILLED OUT, TO THE LOCAL REGISTRAR OF HUIS DISTRICT WITHIN TEN (10) DAYS FROM THE DATE OF INTERMENT OR CREMATION IF NO PERSON IS IN CHARGE, THE FUNERAL DIRECTOR MUST SIGN THE ABOVE STATEMENT, WRITING ACROSS THE FACE OF THIS PERMIT THE WORDS "NO PERSON IN CHARGE" . AND FILE THE PERMIT WITHIN TEN (10) DAYS WITH THE LOCAL REGISTRAR OF THE DISTRICT IN WHICH THE CEMETERY IS LOCATED.
STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH VITAL STATISTICS
AUG 11 1932
·2000 3.12 100M CALIFORNIA STATE PRINTING OFFICE
FATHER
13. NAME
Alda MacDonald
14. BIRTHPLACE (CITY OR TOWN)
STATE OR COUNTRY
Scotland
MOTHER
15. MAIDEN NAME
Jean Allen
16. BIRTHPLACE (CITY OR TOWN )
STATE OR COUNTRY. Scotland
17. LENGTH OF RESIDENCE
25. IF DEATH WAS DUE TO EXTERNAL CAUSES (VIOLENCE) FILL IN THE FOLLOWING: ACCIDENT, SUICIDE DATE OF INJURY. OR HOMICIDE ?.
INJURED _ CITY OR TOWN OF
AT
1
COUNTY AND STATE OF.
DID INJURY OCCUR IN HOME, INDUSTRY, OR PUBLIC PLACE ?. MANNER OF
INJURY.
NATURE OF
27. SIGNATURE
K. W. Binkley
M.D.
PHYSICIAN, AUTOPSY SURGEON
Selma, Calif,
ADDRESS
28. WHEN REQUIRED
BY LAW.
J. Herman Kennedy
CORONER
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD READ THE PRINTED MATTER CAREFULLY
IF NON-RESIDENT, GIVE
ST.
CITY OR TOWN, AND STATE Winthrop, Mass.
female
white
23. MEDICAL CERTIFICATE OF DEATH
I HEREBY CERTIFY, THAT I ATTENDED DECEASED FROM
TO.
THAT I LAST SAW H.
ALIVE
.. M.
12. BIRTHPLACE (CITY OR TOWN)
STATE OR COUNTRY.
New York
IF LESS THAN
OCCUPATION.
COUNTY OF.
Fresno
I. E. FARLEY
CLERK
1051
-
١
-
ر
Name, sugente (Christine ) e.c.r.s.
Place of Death,
Street
Maris
1
No. .
Ward,
Village, fatty.
How long a resident It Months
Previous residence, Minthron Mass
If death occurred at an institution give name of same
How long an inmate,
Where from,
.
Date of Death: Year, 22 Month, Day, 18
Age: Years,. ... ..... Months, .. ... . Days, ..
Place of Birth, lasice
Date of Birth: Year, ...... Month, ...... Day, ...
Sex, ........ Color,.
Married, Single,
Widowed or
Divorced
Widow
Occupation,
Retired
th aringme thyroid
with metastases
. Duration, gravi
Contributing Cause,
·
Duration,
Name of Father,
Maiden Name of Mother,
Birthplace of Father,
.
Birthplace of Mother,
Occupation of Father,
[Record continued over.]
DEC 7 1932
13568
Deceased was wife of .... Widow of Lundion Deara
Name of physician (or other person) reporting said death . Francis Jornal. P. O. Address, 2 Salbut ICH Place of Interment, Winthrop Mass Date of Interment,20-132
. . Name of Cemetery, Mimar 5 Undertaker Michael Porcelli 10726. Bennett Si- P. O. Address, ..........;
The State of New Hampshire
I hereby certify that the above death record is correct to the best of my knowledge and belief.
Clerk of
Det 196
STANDARD CERTIFICATE OF DEATH
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
1. PLACE OF DEATH
County
Cheshire
State
Registered No.
224
Township
Jaffrey.
or Village
or
St ..
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
mos. _ ds. How long In U. S. If of foreign birth?
- yrs. .
mos ..
____ ds.
2. FULL NAME
Eugenie Civistine Sean
(a) Residence: No.
(Usual place of abode)
(If nonresident give city or town and State)
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
13. SEX
4. COLOR OR RACE
5. SINGLE. MARRIED. WIDOWED.
OR DIVORCED (write the word)
wid.
21
DATE OF DEATH (month, day, and year) nov. 18. 1932
22.
I HEREBY CERTIFY, That I attended deceased from
19_
to
19
5a. If married, widowed, or divorced
HUSBAND of
(or) WIFE of
last saw h alive on. 19 ; death Is said
6. DATE OF BIRTH (month, day, and year) -
-1866
7. AGE
66
Years
Months
Days
If LESS Hen
1 day
hrs.
The principal cause of death and related causes of Importance
were as follows:
Carcinoma thyroid
or
min.
8. Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc
Retired
9. Industry or business In which work was done, as silk mill, saw mill, bank, etc.
10. Date deceased last worked at
this occupation (month and
year).
11. Total time (years)
spent in this
occupation
12. BIRTHPLACE (city or town)
(State or country)
France
13. NAME
14. BIRTHPLACE (city or town)
(State or country)
un.
15. MAIDEN NAME un.
16. BIRTHPLACE (city or town)
(State or country)
Where did Injury occur? (Specify city or town, county, and State) Specify whether Injury occurred In industry, In home, or In public place.
Manner of injury
18. BURIAL, CREMATION, OR REMOVAL
Place
Date
19
19. UNDERTAKER
(Address)
1933
124
Was disease or Injury in any way related to occupation of deceased?
If so, specify
(Signed)
CH Waymah
M. D.
20. FILED 19
Registrar.
(Address)
6 Jaffrey n
H
FATHER MARGIN REOLITYED PORT DINDING OCCUPATION
OCCUPATION is very important. See instructions on back of certificate.
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of
information should be 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
MOTHER
17. INFORMANT
(Address)
Other contributory causes of Importance:
Name of operation Date of
"What test confirmed diagnosis ?.
Was there an autopsy?
23. If death was due to external causes (violence) fill In also the following: Accident, suicide, or homicide? Date of Injury. 19
--
with metastasen
9 yrs.
V. S. No. 98
c 11-10931
City
No.
Length of residence In city or town where death occurred
-yrs.
St.,
Ward.
Winthrop, Mas.
4
tp have occurred on the date stated above, at
m.
Dale of onset
Nature of Injury
MAR "
UNITED STATES STANDARD CERTIFICATE OF DEATH
Statement of occupation .- Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the deceased had retired from business, report the occupation prior to retirement. Children not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housewife in answer to Question 8 and own home in answer to Question 9. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as servant-private family, cook-hotel, etc. For a person who had no occupation whatever write none.
To be complete, an occupation return must state:
8 .- The trade, profession, or particular kind of work done.
9 .- The industry or business in which the work was done.
10 .- The month and year the deceased last worked at the occupation.
11 .- The number of years the deceased followed the occupation.
In stating the occupation, avoid the use of such indefinite terms as "employee," "worker," "operative," etc. Find out the particular kind of work done and return that, as spinner, weaver, etc.
In stating the industry or business, avoid the use of such general terms as "store," "factory," "mill," etc. State the particular kind of store, factory, mill, etc., as grocery store, soap factory, cotton mill, etc.
Distinguish carefully the different kinds of engineers by stating the full descriptive titles, as civil engineer, mechanical engineer, mining engincer, stationary engineer, etc. Avoid the term "laborer" when a more precise statement of the occupation can be secured. Do not use the word "mechanic," but give the exact occupation, as carpenter, painter, machinist, etc. Distinguish carefully between retail merchants and wholesale merchants. A person who sells goods should be called a salesman and not a clerk.
Statement of cause of death .- Cause of death means the disease, injury, or complication which causes death, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease or injury causing death. As related causes, name carlier morbid conditions, if any, related to the principal cause and any important complication of the principal cause. Under other contributory causes of importance, name other important diseases or injuries. Examples:
Example I
Example II
The principal cause of death and related causes of importance were as follows:
Date of onset
The principal cause of death and related causes of importance were as follows:
Date of onset
Arteriosclerosis
1915
Attack of epilepsy
1 week ago
Chronic interstitial nephritis
1921
Run over by street car
1 week ago
Cerebral hemorrhage
July 5, 1927
Peritonitis
3 days ago
Other contributory causes of importance:
Other contributory causes of importance:
Gallstones
May 1, 1923
Gastroenteritis
1 year
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY PHYSICIAN
U. S. GOVERNMENT PRINTING OFFICE: 1030
c11-3184
ORM R-302
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of informa- OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very tion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE MARGIN RESERVED FOR BINDING
PLACE OF DEATH
(County)
Boston
(City or Town)
No.
Huntington Hospital
.St.,
Ward
give its NAME instead of street and number)
2 FULL NAME
Isadore Brown
(Order of Court)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence.
No.
42 Ocean Ave
.. St.,.
WardWinthrop
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred
yrs.
mos.
days.
How long in U. S., if of foreign birth?
yrs.
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
18 DATE OF
DEATH
Married
December
26.
1932
(Month)
(Day)
(Year)
19
I HEREBY CERTIFY, That I attended deceased from
Dec
19 .... 3 .? to
Dec
2.6.
19.
.32
I last saw him .... alive on
Dec.
.. 2.5.,
19 .. 3.2., death is said
to have occurred on the date stated above, at ... 1: 0.5Am. The principal cause of death and related causes of importance in order of onset were as follows:
Dafeofonset
Chr ...... Lymphatic .. leukemia
1925 ...
Contributory causes of importance not related to principal cause:
Decondary Anemia
1929
Name of operation
Date of
What test confirmed diagnosis?
Was there an autopsy?
20 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
A.M .... Brues
M. D.
(Address).
Boston, Mass.
Date/26/ 19
3.2
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
Jewish
l"Toburn
(Cemetery)
Dec
26,
(City or town)
DATE OF BURIAL
19
32
17
Informant
Benjamin ... Bororsky
(Address)
Tinthrop Mess.
A TRUE COPY.
ATTEST:
(Registrar of city or town where dcath occurred)
DATE FILED
Dec 28,
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