USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 10
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eulosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- eoma, etc., of. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronie 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 diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," " 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 unknowu, as A person found dead, etc.
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
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
Nest Chelamfad (No. Mars
St. :
Ward)
2 FULL NAME Sonar. M. nelson.
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Jest. Chelmsford. Mars
Elonar- 12 nelson
Registered No.
73
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
1
(Year)
7 AGE
If LESS than
I day ......... hrs.
11 yrs.
2
mos
9
mos.
ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
School Chil.
(b) General nature of industry,
business, or establishment In
which employed (or employer).
9 BIRTHPLACE
(State or country)
Sweden.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Sweden.
12 MAIDEN NAME
OF MOTHER
agnes, austria
13 BIRTHPLACE
OF MOTHER
(State or country)
0
Sweden.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) Mr. august Malzon
(Address)
I went Chelovad Man.
16 Filed .. SEhit 20, 1910 Edward , Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
Self-13
., 1910,
to
8/21-20
191.
that I last saw he alive on
821- 20
191 0
and that death occurred, on the date stated above, at 4 /4" m.
The CAUSE OF DEATH* was as follows :
Ly Johnid Jeen
.....
(Duration)
yrs.
.mos.
ds.
...
Contributory.
hung compleacher
(SECONDARY)
(Duration)
. yrs.
mos.
2-ds.
(Signed)
Seal, 21, 1910 (Address).
21
* 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
DATE OF BURIAL
great Chefmed Canning Cant 21
1910
20 UNDERTAKER
David & Greig
ADDRESS
Hertard Mia 22
20
1918
6 DATE OF BIRTH
Prily 20
(Month)
1899
(Day)
23.2 Chefmand. (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
MARGIN RESERVED FOR BINDING
important. See instructions on back of certificate.
10 NAME OF
FATHER
August- nelson.
M.D.
8
1
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 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-
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 disease ; Chronic interstitial nephritis, ctc. The contributory (second- ary or intercurrent) affection necd 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," ctc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicemia," "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.
2
233
Chelmsford (City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME Clifford L. W.Gaudette
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Princeton St.North Chelmsford
Registered No.
74
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Male
White
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word) Single
6 DATE OF BIRTH
May 9
(Month)
(Day)
I9IO (Year)
7 AGE
If LESS than
1 day, hrs.
4
mos. 13 ds.
or ....... min. ?
8 OCCUPATION (a) Trade, profession, or Particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
North Chelmsford Mass.
10 NAME OF FATHER
Walter Gaudette
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Canada P.Q.
12 MAIDEN NAME OF MOTHER
Nellie Sucey
13 BIRTHPLACE OF MOTHER (State or country) Wilton N.H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Haltes veredett, rather
(Address) Worth Chelseater & Mass
16 Filed. Sept 23 1910 Edward Si Robbing
& REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
22 19! 6
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Soft- 4 1910 to
Seff. 22
1916
,
that I last saw hemalive on.
Rele-21
, 1910
,
and that death occurred, on the date stated above, at / m.
The CAUSE OF DEATH* was as follows :
Entero colitis
(Duration)
yrs. ...
18
.ds.
Contributory (SECONDARY)
.. (Duration) yrs.
mos. ds.
(Signed)
7 ENannen
weft. 22 190 (Address)
n. Chilunter
M.D.
* 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.
mos.
ds.
Where was disease contracted, if not at place of death ?.
Former or usual residence. .......
19 PLACE OF BURIAL OR REMOVAL
act Cheles Ford
DATE OF BURIAL West 23. 1910
20 UNDERTAKER -
ADDRESS
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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 Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH 1 PLACE OF DEATH
North Chelmsford .... (No ....... Princeton ... St. St. :
Ward)
In the
yrs.
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- 1 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 Ilouse- kcepers 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 110 occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE ('AUSING 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 cercbro-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- eoma, 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 septicemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
1
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.
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 1 PLACE OF DEATH
North Chelmsford (No. Middlesex Street St. :
Ward)
Chelmsford (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME James Quigley
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Mary Carroll Middlesex Street North Chelmsford
Registered No. ~5
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
male
white
5 SINGLE MARRIED WIDOWED, OR DIVORCED (Write the word)
widowed
6 DATE OF BIRTH
--
1843 (Year)
AGE
If LESS than I day, ....... hrs.
67
yrs.
mos.
ds.
or ....... min. ?
8 OCCUPATION
Retired
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
Formerly laborer in
Iron Foundry
9 BIRTHPLACE
(State or country)
Ireland
10 NAME OF FATHER
Not known
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Ireland
12 MAIDEN NAME OF MOTHER Not known
13 BIRTHPLACE OF MOTHER (State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Jamo 1 Vengoley,
(Address) hall Chefiva Incl
16 Filed. Sept. 29, 1910 Edward Y Retling
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from Salut 15, 1910, to. Salut .28. 19/0,
that I last saw him alive on. Sept 28. 19/0, and that death occurred, on the date stated above, at 3.30 G.m. The CAUSE OF DEATH* was as follows :
Senils Debility
(Duration)
.yrs.
mos. ds.
Contributory. (SECONDARY)
(Duration)
yrs.
mos. .ds.
(Signed)
James
f. Arban
M.D.
Sept 280, 1910 (Address) No. Janla
* 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
St Patricks cemetery
DATE OF BURIAL
Sept 30,
191
20 UNDERTAKER
ADDRESS
.
16 DATE OF DEATH Selit 28 (Day)
(Month)
191.0. (Year)
(Month)
(Day)
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
234
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, Architeet, 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: («) 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 - Coul mine, otc. 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, Hlousework, 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-
culosis of lungs, meninges, peritonaeum, etc., C'arcinoma, Sar- coma, etc., of (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasmns) ; 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 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.
ADDRES
Wennbeck so thiadler
GIBTHAR abur- Cl
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" Worth thelinefand IN
2 FULL NAME William Fletcher
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE North Chelinford mass
Registered No. 304 76
PERSONAL AND STATISTICAL PARTICULARS
3 SEX male
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
6 DATE OF BIRTH
(Month)
7
(Day)
1844
17
(Yeaf)/
7 AGE
66
yrs. 17 mos
mos.
24 ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
merchant
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Lynn nova Scotia
10 NAME OF
FATHER
Charlee Lewis
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Hana Scotia
12 MAIDEN NAME
OF MOTHER
Catherine Reed
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Jusun PLenen Wife
(Address)
15
File Oct. 4, 1910 Eduard R. Nothing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
(Month)
(Day)
1910
(Year)
I HEREBY CERTIFY that I attended deceased from
Sell-20
, 1910
Del- 1
., to
1910
that I last saw hu alive on
Oct- 1
1910
,
and that death occurred, on the date stated above, at 93000 m.
The CAUSE OF DEATH* was as follows :
Organic
decesar of heard
(Duration) ..
3
yrs.
mos.
ds.
Contributory. (SECONDARY)
.. (Duration) .
yrs.
mos.
ds.
JE tamly
M.D.
(Signed)
Del- 2
., 191 0 (Address).
7. Chehus ferd
* 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
Southampton NS
DATE OF BURIAL
cect 4
1910
ADDRESS
20 UNDERTAKER
Jahm. a Wennback to middlesex
235
(City or town.)
St. : Ward)
Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
16 DATE OF DEATH
1x1
If LESS than
I day ..... . hrs.
....
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) Salcs- 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, Laborcr - 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-
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