USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 1
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N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
١
166 Chelmsford.
1 PLACE OF DEATH
County.
Middlesex
State
Mass.
Township ...
6 helmsford.
City
No.
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Pauline H. Kidder
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.,
Ward.
(If non-resident give city or town and State)
Length of residence in city or town where death occurred years
months
days.
llow long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female.
4 COLOR OR RACE
White.
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) Single.
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
G DATE OF BIRTH (month, day, and yea Seht. 5. 1880.
7 AGE
33
Years
Months
3
/ Days
28
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work
blesk.
(b) General nature of industry, business, or establishment in which employed (or employer) .. (c) Name of employer
Register of Feeds.
9 BIRTHPLACE (city or town). (State or country) Macer
10 NAME OF FATHER Charles H, Kidder
11 BIRTHPLACE OF FATHER (city or town) Lowell
(State or country) Mass
12 MAIDEN NAME OF MOTHER Blasa 6 Fill.
13 BIRTHPLACE OF MOTHER (city or town) ....
Lowell
(State or country) Marx.
14
Informant
Hora, Clara & Kidder.
(Address) Chelmsford, Mara,
15 ed. Jan. 4. 2019 Edward YilSims 0
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Jan, 2 1919.
17 I HEREBY CERTIFY, Thay I attended deceased from Dec. 28 1918, ..... , to ..... y
that I last saw het alive on
...........
1919.
, 19.19.
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows :
(duration)
... yrs ..
mos.
7
ds.
CONTRIBUTORY (SECONDARY)
.(duration)
yrs ..
... mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death? No Date of
Was there an autopsy ?.
no.
What test confirmed diagnosis?
(Signed)
II.D.
1-1, 191 (Address) * State the DISEASE CAUSING DEATII, or fn deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
DATE OF BURIAL
-
19 PLACE OF BURIAL, CREMATION, OR REMOVAL . Lowell Cemetery, Jan, 4, 1919.
20 UNDERTAKER
Gromhealey
ADDRESS 79 Branch 8%.
8161 33
178 5
MARGIN RESERVED FOR BINDING
of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Registered No.
or
or Village ....
Bartlett
St.,
.Ward
(a) Residence. No. Bartlett
(Usual place of abode)
11 A
.m.
Lowell,
PARENTS
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
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 agc. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive 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 necded. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dcaler," 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 Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically 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 indi- cated 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 discasc. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopncumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, 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 (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (increly symptomatic), "Atrophy," "Col- lapse,". "Coma," "Convulsions," "Debility" ("Con-
genital," "Senile," etc.), "Dropsy,". "Exhaustion," 'Heart failure," "Hemorrhage," " "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ctc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- terminc definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Casas for the Medical Examiners. - Under the provi- sions 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, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the strcet, or one supposed to bc due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
Pamvero
(City or town)
Registered No.
(Place of death)
Registered No ...
2
(Plaèe of residence)
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
annette Goodwin
City or Town Chelmsford No.
Length of residence in city or town where death occurred
years
4
mooths
3 days
How long in U. S., if of foreign birth?
years
months
days
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
un. 6
19 / 9
17
HEREBY CERTIFY, That I attended deceased from
Sept. 3
1918 No fare. 15
, 19/9
that I last saw h. el alive on ...
19/9.
and that death occurred, on the date stated above, at 1:30 am The CAUSE OF DEATH* was as follows :
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (Sce reverse side for additional space.) Broncho-pneumonia
.....
... (duration) ...
.. yrs ..
... mos ................. ds.
.....
CONTRIBUTORY
(SECONDARY)
(duration)_
.yrs. ...
..... mos.
ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death?
Date of
Was there an autopsy ?.
What test confirmed diagnosis ?.
.....
(Signed)
Waldryan
M.D.
...
1/7.1919 (Address) Hathorne Mass.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
White River Function, t. Jane. 9 1919
DATE OF BURIAL
15 Jan 9 1919 Julius Scale
Registrar of city or town where death occurred
Filed / 0
Registrar of city or town where deceased resided
20 UNDERTAKER young + Blake
ADDRESS Lowell
MARGIN RESERVED FOR BINDING
1 PLACE OF DEATH
County
Esel
City or Town.
Hanvers
(a) Residence.
State
Maso
(Usual place of abode)
3 SEX
4 COLOR OR RACE
Female White
7 AGE
Years
73
Months
7
Days
1
If STILLBORN, eoter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
.
particular kind of work
None
(h) Geoeral oature of industry,
business, or establishment io
which employed (or employer) ...
(c) Name of employer
9 BIRTHPLACE (city or town) .........
Sharon
PARENTS
14
of certificate.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
Jan. 29, 1919 VOdevard"
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be
so that it may be properly classified. Exact statoment of OCCUPATION is very important. See instructions on back
(State or country)
Vermont
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
George Goodwin
6 DATE OF BIRTH (month, day and years June 5.1845
If LESS thao
I day, ........ hrs.
or ....... mio.
10 NAME OF FATHER Joseph Sargent
11 BIRTHPLACE OF FATHER (city, or town) ........
(State or country)
Unknown
12 MAIDEN NAME OF MOTHER Thail Roberts
13 BIRTHPLACE OF MOTHER (city or town) .....
(State or country)
Unknown
Informant
Custos Poch
(Address) Hathorne Mars.
State
No.
Lauvers State Hospitals.
.................. Ward
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.
PERSONAL AND STATISTICAL PARTICULARS
167
...........
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
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, Compos- itor, Architect, Locomotive 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborcr, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At homc. Care should be taken to report spe- cifically 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nonc.
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: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopncumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, 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 (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 Gs .; Broneho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" (“Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- P'ERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or IIOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions 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, Exposurc, 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.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS
BY
PHYSICIAN.
R 303. 6-'18. 50,000.
MARGIN RESERVED FOR BINDING
1 PLACE OF DEATH Clasai 1 County 2 FULL NAME. (Usual place of abode) Length of residence io city or town wbare death occurred years 3 SEX emale 5à If married, widowed, or divorced HUSBAND of (or) WIFE of Formick W. 6 DATE OF BIRTH (month, day, and year) Months Days 7 AGE Years 40 (a) Trade, profession, or particolar kiod of work. (b) General nature of industry, bosiness, or establishment io which employed (or employer) (c) Name of employer 9 BIRTHPLACE (city or town) .... 11 BIRTHPLACE OF FATHER (city or towp) PARENTS 14 C Informant //// (Address) of certificate. carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, 15 N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back (State or country} Gotland
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Trolmaford Massachuscho (City or town) Registered No: 13 worth Chatque ford .or Highland ME SE ... Ward
State
or Village.
Township City No. Ellen Me Donald
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(If in the Army or Navy of the United States, give mark organization, etc.)
(a) Residence. No. Trahland
months
days.
How Inng in U. S., if of foreigo birth ?
years
months days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white onarrival
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
If LESS than 1 day ......... hrs. or ........ min.
8 OCCUPATION OF DECEASED Off home
10 NAME OF FATHER lavanda Bane
(State or country) Igotland
12 MAIDEN NAME OF MOTHER Labelle M- Dans
13 BIRTHPLACE OF MOTHER (city of town) AA (State or country) Scotland
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) au 6
17/
I HEREBY CERTIFY, That I attended deceased from Jan. 6.
19.
... , to.
Jon 6.
1919
that I last saw h.
alive on
and that death occurred, on the date stated above, at .... .m. The CAUSE OF DEATH* was as follows :
1.
Broucho-Quemwound
.... (duration)
rs.
mos ...
12
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
yrs ...
mos. 12 ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death? Date of ...
Was there an autopsy ?
What test confirmed liagnosis ?
(Signed)
7.199 (Address) 29/Budge 8h
M. D.
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional spacc.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL Ju. 8. 199
20 UNDERTAKER
ADDRESS
Filed By/, 1919 Edward YRoffury REGISTRAR
16,8
.St., .Ward.
(If non-resident give city or town and State)
19/9
Bronchi- Ineumong
...........
· Pproved "; v.
" STANDARD CERTIFICATE OF DEATH ses and American Public Health Association]
Statement of occupation. - Precisc 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, c. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, ete. 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial 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 are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- eifieally the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. It 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nonc.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to timc and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of.
(naine origin; "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 &s .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "Col- lapse," "Coma," "Convulsions,"" "Debility" ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "' "Old age," "Shock," "Uremia," "Weakness," ete., when a definite disease can be aseertained as the cause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to dc- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of eause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions 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, Exposure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the strcet, or one supposed to be due to Alcoholism, ete.
4. Deaths under circumstances unknown, as A person found dead, ete.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
R 15. 1-'18. 100,000.
MARGIN RESERVED FOR BINDING
Township City 3 SEX Female 7 AGE PARENTS carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, of certificate. N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back particular kind of work
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County.
Middlesex
State
Mare.
Registered No ...
or Village Chelmsford Center.
No ..
or North Road. St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Lizzie F. Hibbert
(If in the Army or Navy of the United States, give rayik, organizationsetc.)
(a) Residence. No. north Road Chelmsford Cestu
.Ward.
(If non-resident give eity or town and Stato)
Length of resideoce io city or town where death occurred
4
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widow
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
of Charles S. Hilbert
6 DATE OF BIRTH (month, day, and year) Qc+ 3.1856.
Years
62
Months
3
Days
9
If LESS than 1 day, ........ brs. or ........ min. -
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
at Home
(b) General nature of industry, business, or establishmeot in wbich employed (or employer) (c) Name of employer
at HOME
9 BIRTHPLACE (city or town) ...
Lowell
(State or country)
mass.
10 NAME OF FATHER
abel E. Connant
11 BIRTHPLACE OF FATHER (city or town) Hardwick.
(State or country)
Vermont
12 MAIDEN NAME OF MOTHER Frances Sloan
13 BIRTHPLACE OF MOTHER (eity or town) Balandvale (State or country) mase.
14 Edwin Whitcomb
Informant
(Address) North Road Chelunsford Center
15 ed Jan. 13, 1919. Edward 9 Rotting REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Jan 12, 1919.
17
I HEREBY CERTIFY, That I attended deceased from
Jan. 1
1918
., to.
Jan 12, 1919.
that I last saw he ....... alive on
Jan. 12 th
,1919.
and that death occurred, on the date stated above, at 6 P.
.m. The CAUSE OF DEATH* was as follows : Muranoman of Seven
(duration)
1
.. yrs.
mos ..
ds.
.
CONTRIBUTORY.
(SECONDARY)
(duration)
... yrs ..
mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
710. Date of X
Was there an autopsy ?.
no .
What test confirmed diagnosis ?.
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