Deaths 1917-1918, Part 1

Author: Chelmsford (Mass.)
Publication date: 1917-1918
Publisher:
Number of Pages: 396


USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 1


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.


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


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


(No. non Calmo ford.


St. : Ward)


2


2 FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE


.....


Auth Chelmsford


Registered No. . 1


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


{ COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Married


· DATE OF BIRTH


(Month)


(Day)


1


(Year)


7 AGE


If LESS than


[ day .......... hrs.


........... yrs ....


or ......... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


as hroma.


(b) General nature of industry, business, or establishment in which employed (or employer) .....


9 BIRTHPLACE


(State or country)


Sidney Marina.


PARENTS


12 MAIDEN NAME


OF MOTHER


Minibuch Bailey


18 BIRTHPLACE


OF MOTHER


(State or country)


Oakland Wann


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Elhredan Varmes.


(Address)


18 Filed (


1917 Edward 9. Rod Brin


REGISTRAR


17


I HEREBY CERTIFY that I attended deceased from


Dee.23


1916.


to. Van. 2 1917 ............ that I last saw her alive on Jama 199 and that death occurred, on the date stated above, at 5 A.m. The CAUSE OF DEATH* was as follows :


Quando Fremmona


(Duration) ..


.......


.... yrs.


................ mos.


ds.


Contributory


(SECONDARY)


mos.


(Duration) ............ y16)


.. ds.


(Signed)


H. Love Dage


M.D.


Jun. 3, 1917 (Adress Lowell, Mass.


* 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. ...... ......


DATE OF BURIAL


19142


:0 UNDERTAKER


ADDRESS 96Promet ..


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


Burnfiona Thomas.


11 BIRTHPLACE


OF FATHER


(State or country)


Thomas.


223


(City or town.) -


fIf death occurred in a hospital or institution, give its NAME instead of street and number.]


Garitta Thomas Elbridge Varney.


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month)


forma


2


(Day)


1917


(Year)


-


........


19 PLACE OF BURIAL OR REMOVAL


....


83 9 .. mos. 5 0 ds.


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, c. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive enginccr, Civil engincer, 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 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 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 use of "Tumor" for malignant neoplasms) ; 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: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mere)y 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 Aiscases 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 disease, as A death upon the street, or onc supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


R. 15-8-'15. 100,000.


WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


Wulmstorf Centra (No


..........


St. ;


Ward)


2 FULL NAME


Mary " S marner


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


Chelmsford Mass


Registered No.


2


PERSONAL AND STATISTICAL PARTICULARS


5 SINGLE,


MARRIED,


WIDOWED,


Single


OR DIVORCED


(Write the word)


$ DATE OF BIRTH


Aux 15 1846


(Day)


1


(Year)


Or ......... min. ?


9 BIRTHPLACE


(State or country)


Chelmsford Mass


10 NAME OF


FATHER


John Turner


11 BIRTHPLACE


OF FATHER


(State or country)


Chelmsford Mads


12 MAIDEN NAME


OF MOTHER


Julia Snow


Billerica


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


Lowell Mass


16 Filed. Jan. 6 , 1917 Geleverd Fr Salling


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Jan 5 1917


17


I HEREBY CERTIFY that I attended deceased from


Die. 16


191


to.


191


7:


that I last saw h &M alive on


Dec 16.


1917


and that death occurred, on the date stated above, at /0G. m.


The CAUSE OF DEATH*,was as follows :


Myocardial Degeneration.


I have not even the patient since


ds.


Dre. 16.1916. The had Christian


................ yrs.


.. mos.


Contributory


Science " Treatment


(SECONDARY)


(Duration)


........ yrs.


.mos.


...................


(Signed)


Jan. 6, 1917 (Adres).


Chulunsford, maks.


* 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.


....


In the


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


Fox Hill Cemetry


Billerica


DATE OF BURIAL


Jan 9, 1917


20 UNDERTAKER


Youngwy Blake


ADDRESS


33 Prescott


MARGIN RESERVED FOR BINDING


1 PLACE OF DEATH


3 SEX


Female


4 COLOR OR RACE


White


(Month)


7 AGE


8 OCCUPATION


At Home


(a) Trade, profession, or


particular kind of work


(b) General nature of industry,


business, or establishment In


which employed (or employer) ..


PARENTS


13 BIRTHPLACE


OF MOTHER


(State or country)


(Informant) BOSCO Mupr ..


important. See instructions on back of certificate.


(Address)


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


10


...... yrs ...


................. mos.


If LESS than


1 day ......... hrs.


ds.


22 21


Chelmsford (City or town.) [If death occurred in a hospital or institution, give its NAME instead . of street and number.]


(Month)


(Day)


191


(Year)


...


M.D.


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 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 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 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, peritonacum, etc., Carcinoma, Sar- roma, 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," "Uraemia," "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 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 disease, as A death upon the street, or onc supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


R. 15-8-'15. 100,000.


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


important. See Instructions on back of certificate.


The Commmuralth of Massachusetts


STANDARD CERTIFICATE OF DEATH


I PLACE OF DEATH


Chelmsford.


....


(No.


First


St. :


Ward)


(City or town.) {If death occurred in a hospital or institution, give its NAME Instead of street and number.]


Registered No.


3


PERSONAL AND STATISTICAL PARTICULARS


8 SEX m


· COLOR OR RACE


JINGLE,


MARRIED


WIDOWED


· DATE OF BIRTH June


22 1849


(Month)


(Day)


(Year)


7 AGE 67


yrs.


6 . 15


ds.


Or ......... min. ?


$ OCCUPATION


(a) Trade, profession. or


particular kind of work


Machinist


(b) General nature of Industry, business, or establishment In which employed (or employer) ...


9 BIRTHPLACE


(State or country)


" Kent les. England.


PARENTS


12 MAIDEN NAME


OF MOTHER


Mary Kemp


13 BIRTHPLACE


OF MOTHER


(State or country)


England


"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant).


Mus lem. Hele (wife)


(Address)


16


Filed Jan. 2, 1917 Edward J. Bobbing ................... REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


January


6 th


1917


...


(Month)


(Day)


.


(Year)


17


I HEREBY CERTIFY that I attended deceased from


Jan. 2nd, 1917, to


Jan leth


1917


.......


that I last saw h.k.x21 alive on


(Jan, 6th, 1917.


and that death occurred, on the date stated above, at /P.m.


The CAUSE OF DEATH* was as follows :


Broncho - Pneumonia


.... (Duration) .


............. yrs.


.. mos. ....


7 de.


.....


Contributory.


(SECONDARY)


(Duration)


.........


yrs.


„mos.


de.


(Signed)


CImara toward


M.D.


Jan. 8, 1917 (Adres).


Chelmsford.


0 * 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.


In the


ds.


State ...


mos.


......


Where was disease contracted, If not at place of death ?.


Former or usual residence. ................................... ................


....


19 PLACE OF BURIAL OR REMOVAL


fattur cy- mass.


ATE OF BURIAL


Jan. 9


191


ADDRESS


20 UNDERTAKER


Wallen Perham


MARGIN RESERVED FOR BINDING


WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.


.


Charles Morris Hills


? FULL NAME {If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE


225


10 NAME OF~


FATHER


James Hello


11 BIRTHPLACE


OF FATHER


(State or country)


England.


if LESS than


1 day ........ hrs.


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 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) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborcr," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborcr - Coal mine, etc. Women at home, who are engaged in the dutics of the household only (not paid House- kecpers 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: Farmcr (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.


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 diseasc. Examples: Cerebro-spinal fevcr (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-


culosis 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; 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 mcre symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mercly 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 diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical opcration 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 disease, as A death upon the street, or onc supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dcad, ctc.


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


( PLACE OF DEATH Nowel mass (No St. John's Hospital


-226


Lowell ......


(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]


2 FULL NAME


Eleanor Derney - Edward


no. Chelmsford mass


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


4 COLOR OR RACE


termale White


& DATE OF BIRTH


(Month)


(Day)


(Year)


AGE


20


... yrs.


mos.


.ds.


or ........ min. ?


· OCCUPATION


(a) Trade, profession, or


particuler kind of work ...


at Home


(b) General nature of Industry, business, or establishment in which employed (or employer).


9 BIRTHPLACE


(State or country)


Lowell mass


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Ireland


12 MAIDEN NAME


OF MOTHER


margaret Bowen


18 BIRTHPLACE


OF MOTHER


(State or country)


frel and


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


William Horney


(Address)


16 Filed art. 1 -1 191.


Gerne REGISTRAIL


16 DATE OF DEATH


January


3


(Month)


(Day)


191 (Year)


17 I HEREBY CERTIFY that I attended deceased from November 23 1916, to January 1 1917 that I last saw hocalive on ... 11 1917 and that death occurred, on the date stated above, at 110 e.m.


The CAUSE OF DEATH* was as follows :


Tuberculosis of Caecum


(Ditation) \


..... yrs. .....


....... mos. ...


ds.


Contributor Surgical Operation


....


(SLCONDARY) U


(Puration ) .


............. yrs.


mos. ds.


M.D.


Jan.11


197 (address St. John's Hospital


{ If death followed injury or violence the certificate of death must bo made gut 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


7 191.


Riverside st Lowell St. PatrickOmeter Jan. 10.


20 UNDERTAKER J. a. molloy kg.


Lowell


MARGIN RESERVED FOR BINDING


WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.


important. See instructions on back of certificate.


Eleanor mardin ....... [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE


Stop Ward)


Registered No.


534


1 5 SINGLE,


MARRIED


WIDOWED,


OR DIVORCED


(Write the word Married


1


If LESS than


! day ......... hrs.


10 NAME OF


FATHER


William herr


John G.


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of oeeu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to caelı and every person, irrespective of age. For many oceupations 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, ete. But in many eases, 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 statemeut. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise speeifieation, as Day laborer, Farm laborer, Laborer - Coal mine, ete. 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 oeeupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, etc. If the oceupation has been changed or given up on account of the DISEASE CAUSING DEATH, state oeeupation at beginning of illuess. If retired from business, that faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oeeu- pation whatever, write None.


Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the ouly definite synonym is "Epidemie 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, ete., Carcinoma, Sar- coma, ete., of. .(name origin: "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (seeond- ary or intereurrent) affection need not be stated unless iin- portant. Example: Measles (disease eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age,". "Shoek," "Uraemia," "Weakness," ete., when a definite disease ean be aseertained as the eause. Always qualify all diseases resulting from childbirth or misearriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ete. State eause for which surgical operation was undertaken.




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