BSS STATE BUARY Or BEM BUREAU OF VITAL STATISTICS Cinniricare oF DEATH 7 18446- 4. PLACE OF DEATH Reger Batt Rn ca Fi Renney enti UD. A Pow Becotana Dt onan PLOY | retort ef, Low. 4 St. FUL. wan ee. UWelhur. Backes : L 0) Ragen, Nacergeggertenennne engl womens ooo Retort, Seri ise ge a a Levthot tears tener da eer 9, pat ee_ how bnt ie Sn lan? PERSONAL AND STATISTICAL PARTICULARS MEDICAL cRATIFICATE OF REATH = " Je PERTIFICATE @) 18 DATE OF DEATH Gorn Are TD Ffmag 3-030 ne AeA ass 2 occuraTion oF DECEASED ae Oinacmtane Leff det am © Gawain a hs, : covraigutony.. 2 Loemerne arma eee i : enn eee ee 4 a G. ten eee 2 : MOU cage le [Nace a eome Ge Sly. | oe a 7 1, BIRTHELACE OF FATHER (ert 98 Foy & rip Sn tra Vrug Casas, ate ei 'G) wieder hecaashn, Soop aRevised United States Standard Certificate of Death (Approved by U. 8, Cantus and American Pubile Healt ‘Association Statement of Occupation.—Precise statemont of ‘occupation is very important, 60 that the relative healthfulnoss of various pursuits can be known. ‘The question applics to each and every person, irrespec- tive of ago. For many oeoupations a single word or term on the fret Line will bo sufficient, 0. g., Parmer or Planter, Physician, Compotiter, Architect, Locomo- tive Bngincer, Civil Engineer, Stationary Fireman, oto. But {a many oasos, especially in industrial employ- ‘noseseary to know (a) tho kind of work ‘the natura of tho business or industry, ‘an additional pr0% ‘only whon needed. As examples: (a) Spinner, (0) Cotton mitt, (a) Saleo- man, (6) Grocery, (a) Foreman, (8) Automobile fac~ tory. ‘The material worked on may form part of the second statement. Never roturn “Laborer,” “Fore- man,” “Manger,” “Dealer,” ete., without moro prealgo spocifeation, as Dey laborer, Farm laborer, Laborer—Coal mine, oto. Women at home, who aro ‘engaged in the duties of the housohold only (not paid Housekeepere who receive a definite salary), may bo entered as Housewife, Housework or At home, and children, not gainfully employed, as At'school or At home. Caro should be takon to roport specificall the ocoupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, eto. If the ocoupation has boon changed or given up on ‘Account of the DiszAsE CAUSING DEATH, state oooU- pation at beginning of illness. If retired from busi- ress, that foct may bo indioated thus: Farmer (re- fired, 6 yrt.) For porsons ho have no ocsupation whatever, write Non Statement of Cause of Doath—Name, first, the piszase cauerva pears (the primary affection ‘with respect to timo and esusation), using always the ‘sumo acoopted term for the some disease. Examples: Cerebrospinal fever (tha only definite synonym “Epldemlo cerebrospinal meningitis"); Diphtheria (avoid uso of Croup"); Typhotd fever (never report “Typhoid pneumonia”); Lobar pneumonia; Broncho; pneumonia (“Pnoumonia,” unqualified, is indefinite), Tuberculosis of lungs, meninges, peritoneum, Carcinoma, Sarcoma, eto. of. (name o ‘gins “Cancer” is lose definite; avoid uso of “Pum: for malignant nooptasma); Measles, Whooping cough; Chronic ealvular heart di Chronic interatii nephritis, ote. ‘Tho contributory (sccondary or in- terourrent) affection need not be stated unless im- portant. Example: Measles (disoase eausing death), 20 de: Bronchopneumonia (secondary), 10 (merely symptom “Coma,” *Convule “Weakness,” ete, when 9 definite disoaso can bo ssocrtained as tho cause. Always qualify’ all disoases. resulting trom child birth or miscarringo, as “Porarenat, septicemia,’ “Pognennan peritonitis,” oto, Stato causo for which surgical operation was undertaken, For vioLeNT rar! ov inzonr and quality 2 ACCIDENTAL, SUICIDAL, OF HOMICIDAL, OF o8 probably such, it impossible to determine definitely. Examples: Accidental drowning; struck by rail- way train—aceident; Revolver wound of head— homicide, Poisoned by earbolie acid—probably euicide, ‘Tho nature of tho injury, as tracturo of skull, and consequences (0. g., sepsis, fclanus), may be stated ‘under tho head of “Contributory.” | (Recommenda- tions on statement of cause of death approved by Committee on Nomenclature of the American ‘Medical Association.) Nora—Individual oftcos may add to above lst of undeatr- ble term and refuse to accent certificates contalaing them, ‘Thus the form in use to Now York Clty stator: "*CertiDcatos srl be retard for addtional Information which give any of the following leeasce, without explacation, as the cole cause ‘of death: Abortion, eal, elablrth, convulsions, hemor= ‘Phage, eangtene, gatrts, erysipelas, mening, miscarriage, Aocroas, peritonitis, phobits, pyemfo, eepticemia, tetanus,” But general adopsion of the minimem ist euggested wil work ‘rast Improvement, and lta acope can be extended at a Tater