USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 1
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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
anderson Enstal a. anderson John C. audoin
ayotte aubrey Delina adame Framme C.
andrews Lois Otherton Samuel abrahamson arthur
8 Blodgett Frederick Fr. 20
41 Brown Thomas 34 37
101 Buckman alice. M.
52
106 Byam Laura Jane 142 Bondream Sarah 57 59
170 Bridgman Emma S.
185 Buckman Chomac &. 63 77 80
235 Buchanan Mildred G. 241 Burton Chelmia F.
Brown Jeone It. 88
Brault Ieli E 89
Blaisdell trainy 98 107 112
Blood Henry 2. Bailey Frederick Brown William 118
Byam Charles . 132
Byam ann Elizabeth 133
Brooks Olive C. 138
Burke Mary 140
Butcher Frank 163
Butters Estella J. 198
Boucher arthur 204
A B
C D
Carkina Phar. 7. Gallina Halte Casa Orlando & Collins anna y. Churchill Sarah & black Mary B.
Corrigan Frank Campo Leonardo Corn Eliga F Curran Patrick.
Chace Thomas &. Carlson anna S. Coldwell Dorcas R. Carkin James R. Chandler alfred
borr margaret ar
Crowell Charles H.
156
Callahan Som f.
158
Connove Frances R.
159
Carlson Hilda 167
Crowell Lucy a. 178
Coburn Walter H.
194
Clark Sarah 200
Coburn Gratia 226
4 Dutton Surviah P. De Costa manuel m Duffy Edward 11 13 15 18 Duchene Howard 19 Dolloff On a . 22 Donahoe nellie
Luiscoll Mary 1 3 14 33 99 109 126
44 De Carteret 130 % 55 Dutton Bertha H. 14.6 157 81 Luffy Paul Q. 164 169 192 216
70 Sadmin martha Ellen
85 DEcesta
110 Darby
143 Dutten -
1 4X Diflojea --. -
220
153 Daly Robert
244
07 Gatan
Edmunstine Maria
Ellis may a. 22/ Edwards Syltle R. 233
Öster Oliva L. 239
Emnerzon Bust
240
49 83 Finnick mary Frink Emily In. 86 102 127F Fizette marguerite 182 G
Foster Cramel 71.
218
.
4.
38 150
Frites EtEn Frees Thomas Fletcher Joseph m.
E
Goss . Lo Gilder Rita Goulet South Goddard Pling I Greene Olive M.
100 152 181
Graham Glover Joseph th. 230
Grants 232
Grante margaret 236
Gagnon arcelie
40 Harley Minnie B 51 Hazen Cartis G. 62 Hemenway Rodney To. Hildreth Many 9. Howard Grama Co Holland Hugh Hemlow Carb Fr.
228 Janvier Jacob
Hartshor ann 8.
Hart Thomas H
Hille Charles M.
7 28 73 74 84 96 105
Howard mary Hanvar Lucy a. 120 /23 Hagen Frances B Holt Charlie a Harris Sarah a. Holt Sarah a. 145 147 149 151 How muriel matel Howe Gladys Ray 174 176 Hood mary ? 188 190 202 Horne Edward D 209 225 Heilon Gerald 237
Hulslander Peter P. 243
Johson alice S.
-9
10 Jewell Johnson Seaac &. 17
Haffroy Robert G.
67 104
Johnson Lucy a.
Jones Catherine 108.
Jefte William H. 125-
Denne albert E. 160 1
Johnson Sarah Fr. 225J K L
\
Koulos John Kelley John
Kinch michael J. Kilbourne Maria S.
Keenan William
36 Larkin Walter 12
141 Fiddy John S.
213 Lynch Millicent
215 Lundbug Edward FT.
64 Laughton -. 16 97 Larkin abbie 5. 25 42 50 60 72 91 92
Livingston. Joseph I. Geland - Laughton Leighton Elizabeth Leighton Sarah 6. Larose Victor
Liebedzinski Francis
Laughton --
Ligbadzincki 222
Larkin Many a. 227
95% 113 131 1.84 214
murphy James morley George h. : Mechan Elizabeth Melvin Eiga 2. martin Mary E. Milliken Eliza a. miner- Marshall Beverly Or.
mayoun anna S.
Marinel Halten. fr. marshall mary a. E marchand Blitha
Marchand Jean B. H. 201 Miner Emma Q 205
Mansfield George P. Monahan Criam a. 212
melvin Synthia & 229
21 McConnell Hardand 2.9%
35 h Nutty Bridget G. 48 68 Mcmanus John 54 73 Inc Cann 1
76 16 Mc Guinness John
79
117 Milnamen Catherine Q. 3211 :::: 182:
124 Mchavey mary ann 134
148 Mccarthy Rosalina a. 135 166m Manoloin Catherine 173 171 mc Cann William 189
179
186
196
207
M Mc N 0 P
47 56 6/ 121 137 165 168 175 177
Provencher adelaide 197 Gearcon mathilda &
226 Perry Susan a. Cenniman George a. Jours Gerald F. Parkhunch Busting G.
Beckham Samuel it Putney Juliett Polley Winifred 2.
Connie Francis 193 Picken William !. fr. 208 228
Pierce Elvira S.
n nickles Henry Mardin Eleanor
O'Connor Ellen ã 103 O' Hara Frederick 128
Punt De. P .: $
.
6 Ripley Frederick KG 3/ Robinson Thelma a. 46 Richardson Selina G. Peid Russell . 66
78
Kofer Everett a, 119
Richardson Joseph H. 195
Ready Theresa &. 23/
Russen amelia 242
R S T
Whitehead alice
24
Welch Richard Fr.
32
Woodward Myrtle OM.
39
Stand tillie C. 69
Hatch Mary B.
75
Traite Sarah C.
82
ilkins Tu in E.
90
74
Hard nellie W. 122
Staller Julia M.
136
Whatback ann E.
154
Williame 155
Walker Janet
210
217
Wilkinson Mary Wheeler Hofer 227
1
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions 'on back of certificate, N. B. - 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 OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1PLACE OF DEATH Chemsford Centre (No Cold Westford Road )
(City or town.) ...
{If death occurred in a hospital or institution, give its NAME Instead of street and number.]
mary Driscoll
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.] Mary Healey Michal Driscoll
@RESIDENCE
Terrenosford Ventre
Registered No. 1
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female White
4 COLOR OR RACE
5 SINGLE,
Weddound
WIDOWED
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Jan
.....
(Month)
(Day)
(Year)
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
If LESS than 1 day ......... hrs.
mos.
ds.
Or ......... min. ?
8 OCCUPATION
of Coursework
(a) Trade, profession, or
particular kind of work
(b) General nature of Industry,
business, or establishment in
which employed (or employer) ..
at Home
9 BIRTHPLACE
(State or country)
Ireland
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Catherine Buckley:"
18 BIRTHPLACE OF MOTHER (State or country)
Ireland
14 THE ABOVE IS, TRUE TO THE BEST OF MY KNOWLEDGE
(informant),
William Driscoll
(Address) Chersford Ceentre
16
Filed ... form 3 , 1914 Cdward Robbing
REGISTRAR
....
I HEREBY CERTIFY that I attended deceased from
Dec. 265
, 1913 to
Jan. 1 st
1914
that I last saw her alive on
Dec. 31 st
1918
.,
and that death occurred, on the date stated above, at // a.m.
The CAUSE OF DEATH* was as follows :
Bronchitis
.(Duration)
........ yrs.
...
mos. .
14
ds.
Contributory
Senile
(SECONDARY)
... (Duration) .
................ yrs.
.......
.... mos.
ds.
(Signed)
Amara toward
.............. M.D. Jan. 1, 1914 (Address) Chilmand.
......
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death
yrs
mos. ....
ds.
State ..
.......... yrs. ..
............ mos. .........
.. ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
St. Patricks Powell Han 4, 1914
20 UNDERTAKER
ADDRESS
Das H. In Dermott To Gorham
-
1914
7 AGE 76
....
... yrs.
10 NAME OF
FATHER
Michael Healey.
17
.. Ward)
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness 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, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fircman, 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 tlic 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) Sales- man, (b) Grocery; (a) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," cte., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who arc engaged in the duties of the household only (not paid House- keepers who reccive a definite salary), may be entered as Housewife, Houscwork, or At home, and children, not gain- fully employed, as At school or At home. Carc should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, ctc. 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 indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. .(name origin: "Cancer" is less definite; avoid usc of "Tumor" for malignant neoplasins) ; Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age,". "Shock," "Uraemia," "Weakness," ,etc., when a definite disease can be ascertained as the causc. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing 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, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized discase, as A death upon the street, or one supposed to be due to Alcoholism, ete.
4. Deaths under circumstances unknown, as A person found dead, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
2 Chelmsford (City or town.) Ward) Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
St. :
Helen Marion Spaulding
Helen Manfield, arrif & Spaulding
Registered No. 2
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Yan.
3
(Month)
(Day)
1, 94. (Year)
17 I HEREBY CERTIFY that I attended deceased from Drc. 25 .. , 1913, to Jan. 2 1914
If LESS than
I day ......... hrs.
that I last saw her alive on.
Jan. 2
.1.
... ,
1914
and that death occurred, on the date stated above, at 7 a.m.
The CAUSE OF DEATH* was as follows :
Diabetes Mellitus
-
Chronic Interstitial Nephritis.
Diabetes
about 25.
.(Duration)
.yrs.
.. mos.
ds.
Contributory
(SECONDARY)
(Duration)
YES.
mos.
ds.
(Signed)
Authun & Scolonia
M.D.
Jan, 3 1914 (Adress) Chilunsford Mais.
*/If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
in the
. mos.
ds.
State ...
... yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence ....
19 PLACE OF BURIAL OR REMOVAL
Hart Pond Cens
DATE OF BURIAL
Jan 5 1914
20 UNDERTAKER
Matter Parham
ADDRESS
Chelmsford
1 PLACE OF DEATH So. Chelmsford .(No. 2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE PERSONAL AND STATISTICAL PARTICULARS 3 SEX 4 COLOR OR RACE termale white 5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the word) 6 DATE OF BIRTH 5 (Month) (Day) 7 AGE 65% .yrs. 10 mos .. 29 ds. 8 OCCUPATION (a) Trade, profession, or particular kind of work at home (b) General nature of industry, business, or establishment in which employed (or employer). 9 BIRTHPLACE (State or country) Chelmsford 10 NAME OF FATHER L. D. Mansfield 11 BIRTHPLACE OF FATHER (State or country) O Chelmsford 12 MAIDEN NAME OF MOTHER Thamy Reed PARENTS 13 BIRTHPLACE OF MOTHER (State or country) Bedford 14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) C. & Spaulding (Address) Chelmotor CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back of certificate. 15 N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state -
married
1848
(Year)
or ........ min. ?
Filed ....
Jan. 4, 1914 Edward HAKtime
REGISTRAR
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness 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, Compositor, Architect, Loco- motive engineer, 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) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material 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 House- keepers who receive a definite salary), may be entered as Ilousewife, Housework, or At home, and children, not gain- fully 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 occupation 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. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tubcr-
culosis of lungs, meninges, peritonacum, etc., C'arcinomu, Sar- coma, 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 (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," " Old age," "Shock," " Uraenia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions 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, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - 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 OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford
(No.
Wochen 8h
St. :
Ward)
Chelmsford 3
(City or own.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
2FULL NAME Survich Parklurt Dutton
[If married or divorced woman or widow, Suroich Stevens, Saml & Button give maiden name, also name of husband.]. @RESIDENCE Chelmsford
Registered No. 3
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Huncle
4 COLOR OR RACE
white
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Wilno
6 DATE OF BIRTH
March
(Montlı)
(Day)
7 AGE
75
yrs.
10
mos.
11
ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
it have
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Sowell
PARENTS
12 MAIDEN NAME OF MOTHER Survich Manning Parkhurst
13 BIRTHPLACE
OF MOTHER
(State or country)
Chelmente
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
E.F. Dutton
(Address)
Schemetady 41,46
16
Filed. Jan. 18, 1914 Edward Rolfing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jan
16
1911/
(Month)
(Day)
(Year)
1838
17
I HEREBY CERTIFY that I attended deceased from
(Year)
fans
4. to far 17
1914
that I last saw h ... alive on.
If LESS than
1 day ......... hrs.
191.
an 14
1914
and that death occurred, on the dato stated above, at.
m
The CAUSE OF DEATH* was as follows :
Cerebral 1 Liamboris
(Duration)
.yrs.
mos.
os.
Contributory
arteriosclerosis
(SECONDARY)
~ (Duration)
) yrs.
.mos.
ds.
(Signed)
Gi Meandall
M.D.
Jene 1/ 19)
(Address).
Pource
If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death,
... yrs.
.. mos.
ds.
State.
yrs.
In the
mos.
ds
Where was disease contracted, if not at place of death ?.
Former or usual residence. ......
......
19 PLACE OF BURIAL OR REMOVAL
Horefactures Cena
DATE OF BURIAL
Jan 19.
1911
20 UNDERTAKER Walter Perham
ADDRESS
Chelmsford
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
10 NAME OF
FATHER
Jakey Stevens
11 BIRTHPLACE
OF FATHER
State or country) Shaftsbury Ust.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to eachi 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, Compositor, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, ctc. But in many cases, especially in industrial cmployments, 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) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material 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 House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully 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 occupation 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. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
eulosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of ................... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions 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, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - 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 OCCUPATION is very
1 PLACE OF DEATH
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(No. Worcester State Hosp St; .. Ward)
(City or town.) {if death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford, Mass
Registered No. 4
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCEDWidowed
(Write the word)
16 DATE OF DEATH
Jan 24
1914
(Month)
(Day)
(Year)
6 DATE OF BIRTH
1831 1
(Month)
(Day)
(Year)
7 AGE
If LESS than
i day, ........ hrs.
abt 83
... yrs.
.. mos.
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Paving Cutter
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Tyngsboro
10 NAME OF FATHER
Isaac Carkins
11 BIRTHPLACE
OF FATHER
(State or country)
Mass
12 MAIDEN NAME
OF MOTHER
Catherine Lund
13 BIRTHPLACE
OF MOTHER
(State or country)
Vermont
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
W L Orcutt
(Address)
Worcester
15
Filed ..
Jan 201 914 Meuresource
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
Oct 1
191
Qto
Jan 24
1914
that I last saw himalive on.
# 23
1914.
and that death occurred, on the date stated above, a. ...... m.
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