‘may be properly classified. Exact atatement of OCCUPATION ie very importast. (CAUSE OF DEATH Io plaia terms, 00 that = i | MISSOURI STATE BOARD OF HEALTH BUREAU OF VITAL STATISTICS 1. PLACE OF DEATH (CERTIFICATE OF DEATH ig bog ai eae ge iy a a Be de _ How nd in US ill frei Be? em PERSONAL AND STATISTICAL PARTICULARS “3 WEDICAL GRRTIFICATE OF DEATH © SOR ORRIET See atineare |6 owe or orm women woven OG4 23 w/F coh pe oy ii Peay Sk It Maren, Winowea ox Dioaces WUSEAND or : ~ (on) WIFE oF fat at me b.22Z. av of exared on Ge dat ated aber, DATE OF BIRTH (wowrs, DAY AND YE) 17~ 122 — TAGE Yeas | — Nome Det | HUES ria | 2 [Es {OCCUPATION OF DECEASED . (a) Trade, pofestion, ot Mercunefe oscar oh (2) Name of emaerr 2 BIRTHLAGE (a on wom) Dnata Ah. (Stare on cover) - (7 Te, WAME OF FATHER 1 BIRTHPLACE OF FATHER (C7 08 OWN) ovsenranngennsnne (Sra on cour) 12 MAIDEN NAME OF MOTHER Jah Macoeer Dare or. i i 12, BIRTHPLACE OF MOTHER (ro 1 wen (Sure ox cour) eh,Revised United. States Standard Certificate of Death irre iy 0. Gszand teen Pine Ba a : Statement of Occupation —Procje statoment of ‘occupation is very important, so that the relative heslthfulnéss of various pursuits can be known. The ‘question applies to each and overy person, irrespec- tive of age. For many occupations a single word ot torm on the firstline will be sufficient, e.g., Farmer or 1m, Composilor, Architect, Locomo- tive engineer, Civil enpincer, Stationary fireman, ote, But in many cases, especially in industrial omploy~ ents, 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 statomont; it should bo usod only when necided. ‘As examples: (a):Spinner, (b) Cotton mill; (a) Salee- man, (8) Grocery; (@) Foreman, (b) Automobile fac- tory. ‘Tho material worked on msy form part of the second statomont. Never roturn “Laborer,” “Fore- man," “Manager,” “Dealer,” ete., without more precise specification, as Day laborer, Farm laborer, ‘Laborer—Coal mine, oto. Women at home, who ato ‘engaged in the duties of tho household only (aot paid Housekeepers who roesive a definite salary), may be ontered as Housewife, Housework or At home, and children, not gainfully employed, as At school or At home. Caro should be taken to roport specifically ‘the occupations of portons engagod in dom.stio rvice for wages, aa Sereant, Cook, Housemaid, ota, Tt the occupation has boon changed or given up on ‘account of tho DISEASE CAUSING DEATR, stato ovcu- pation at beginning of illness. If rotired from busi- ness, that fact may bo indieated thus: Farmer (re- tired, @ yrs.) For persons who have no occupation whatever, write None. 7 Statement of cause of deat tho pisnasz cavsixa DearE (the primary affection with respect to time and causation), using always the samo accepted term for the same disoaso. Examples Cerebrospinal fever (tho only dofnite synonym is “Epidemic cerebrospinal _moningitis”);, Diphtheria (avoid uso of “Croup”); Typhoid fever (never report + such as “Asthonia,” “Anemi “Typhoid pneumonia’); Lotar pneumonia; Bronchom pneumonia (“Paoumonia,” unqualifiod, is indefinite); Tubereulosia of Iungs, meninges, peritoneum, ote Carcinome, Sarcoma, Olan, Of sme (amo origin; “Cancer” islese dofinite; avoid use of “Turmor” for malignant neoplasms); Measles; Whobping cough; Chronic ealowlar heart disease; Chronte interstitial nephritis, ote. Tho contributory (secondary or in- tercurrent) affoction nood not be stated unless im- portant. Example: Measles (disease caushig death), 29 ds.; Bronchopncumonia (secondary), 10 és. Never report more symptoms or terminal conditions, " (neroly, symptom ati), “Atrophy,” “{Collapeo,” “Conia,” “Conval- sions,” "“Dabilify™” (“Congonitel,” '‘Sonle “Dropay,” 5 ."" “Hart failure,” “Maras,” “Old age, 38," oto.,. Whon o IL diseases resulting from child as “Puxnrenat septiéemia,” - peritonitis,” Stato eauso for which eurgiesl operation” was undertaken. For VIOLENT DEATHS stato aEANS oF INJURY and qualify 8 ACCIDENTAL, SUICIDAL, ON HOMICIDAL, OF 28 probably such, if impossible to dotermino definitely. Examples: Accidental drowning; struck oy rail- way train—accident; Revolver wound of yhead— homicide; Poisoned by carbotic acid—probably auicide, ‘Phe nature of the injury, as fracturo of skull, and consequences (0. g., sepsis, tetanus) may be statod under the hasd of “Contributory.” (Recommenda- tions on statement of eauso of doath approved by Committoo on Nomonelature of ‘the, American ‘Modical Association.) ‘Nors,—Individual ostces may add to above ist of undesi abla terme and refuso to accopt certifeates containing them, ‘Thus the form in uso in Now York Clty sates: “Certieaten will be returned for additional information which give any of the following leeasos, without explanation, tho solo cate ot death Abortion, cellulitis, ehildbirth, convulsions, hemor Thage, gangrenc, gaaiils, oryapelag, mesngtle, miscerriage, ecredts, Pertoatts, phlebitis, pyemia, septicemia, tetanus” Brut general adoption of the mlaimum lst suggested will work vart Improvement, and Ilr wcope can bo extended af a lator date, Avomiowat srace FoR voRTIER GTATEMENTSMISSOURI STATE BOARD OF HEALTH BUREAU OF VITAL STATISTICS ae nnn OED, old state ay... 2. FULL NAME vo (9) Meee, Nees ‘Git pe a Leah reldenc iy or tn here death ‘ii aac ie ce a ta a By PERSONAL AND STATISTICAL PARTICULARS = TOR RACE | on a on ‘ie wand ar = ae SaaS {DATE OF BIRTH (wow, BAY Axo YEA) 7 AGE Yeame | Morne | Bm AGE should be stated BXACTLY. PHYSICIANS 1 OCCUPATION OF DECEASED, (6) Trade ott tetrad ob wet () Gena mtn of ee, piled, (State on courrer) 10, NAME OF FATHER IRTHPLACE OF FATH CAUSE OF DEATH in plein term, 20 thet it may bo properly clasdGed. xact statement of OCCUPATION le very important, REGISTRARS OHALL HOT RECEIVE A FEE FOR CERTIFICATES URTIL THEY ARE COSPLETED AS PRESCRIBED BY LAW. N, B—tvery tem of Information ehould be carefully m gt mms | ener wane of womeet cre on m7 Sa ta Danaen Gromzo Dut, i dita Hn iat Caden ee > 13. BIRTHPLACE OF MOTHER (ert om rom. be Dae Gunes Dae i ay ours oer) Stet” Sapam tints) nm Ee ae ellen _ |i PRET OF BURIAL, CReaATION. OR REMOVAL | DATE OF BURIAL — — o * cans 7. UROERTANER | opres Sifted Tnlf “aie bestia ‘ALL INFORCATION CALLED FOR MUST EE WRITTEN OM THIS SUPPLEMENTARY.