USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 11
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culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- comc, 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 (diseaso causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " All- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," "Old age," "Shock," "Uremia," " Weakness," etc., when a definito 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 strcct, or one supposed to be duc 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.
St. :
Ward)
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.]( @RESIDENCE Chelmsford
Mit Boules Pelis Pefrie Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 1
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED.
OR DIVORCEMarried
(Write the word)
6 DATE OF BIRTH
.24
(Month)
(Day)
(Year)
7 AGE
If LESS than 1 day, ...... hrs.
77 .yrs.
mos.
10
ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Flasurfe
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE (State or country) ) roscommon
more Dieland
10 NAME OF FATHER When Bowles. when
11 BIRTHPLACE' OF FATHER (State or country) Ireland
12 MAIDEN NAME OF MOTHER Catherine Mccabe
13 BIRTHPLACE OF MOTHER (State or country) Dieland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant)
(Address)
15 File Act. 6. 1910 Odmed Setting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Clet.
(Month)
11
(Day)
19! 0
(Year)
18331
17
I HEREBY CERTIFY that | attended deceased from
Cinq 2 7
1910, to.
Oct 4
, 1910.
Oct. 4
that I last saw her alive on. 1910, and that death occurred, on the date stated above, at 8:25 am The CAUSE OF DEATH* was as follows :
Senilità
Cardiac facture
about 2 weeks,
(Duration)
yrs.
mog
ds.
- Contributory.
(SECONDARY)
(Duration)
yrs.
mos. ds.
ArthurG
Scolonia
....
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.
In the
ds.
State
yrs. . .
mos.
ds.
Where was dlsease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL'
Edeon Cern
Powell, Vilaes
DATE OF BURIAL
let 6
191 0
ADDRESS
20 UNDERTAKER
Haller Parliam
236 Chelmsford (City or town.) [If 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.
PARENTS
(Signed)
Cect. 5
191.0 . (Address).
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) Forcman, (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 minc, 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) ; 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, 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," ctc. 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- posurc, 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.
1
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX Female 6 DATE OF BIRTH 7 AGE 8 OCCUPATION (a) Trade, profession, or particular kind of work 9 BIRTHPLACE (State or country) 10 NAME OF FATHER 12 MAIDEN NAME OF MOTHER PARENTS 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 .. . .39
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford Lass (No
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Married
I870
(Month)
(Day)
(Year)
If LESS than 1 day ........ hrs
. yrs. 8. mos. 24
ds.
or ........ min. ?
(b) General nature of industry, business, or establishment in which employed (or employer).
West
Chelmsford
George H. Ackroyd
11 BIRTHPLACE OF FATHER (State or country)
Ballar lyale Mass
Ruth S. Grant
13 BIRTHPLACE OF MOTHER (State or country)
South Tamoton Las
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Edward R. Durant
North
Chelmsford Mask
15 Oct. 8 1910 Edward x, Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
October
6.
17
I HEREBY CERTIFY that I attended deceased from
Od- 6
Sifr-8
1910 to
1910
that I last saw her alive on
Del- 6
1910
and that death occurred, on the date stated above, at 2 30 Pm.
The CAUSE OF DEATH* was as follows :
.(Duration) .
yrs.
mos.
28
ds.
Contributory .. (SECONDARY)
(Duration)
.. yrs.
7 E Varney
mos.
ds.
(Signed)
M.D.
Leer
7
191 0 (Address).
n. Cheliefert.
* 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
DATE OF BURIAL
Ccf 9, 1919
Riverside Cemetery
ADDRESS
20 UNDERTAKER
d.m. trung 33 Prescott of
237
Chelmsfor
n
Blanche E. Durant
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE North Chelmsford Mass
Blanche E. Ackroyd Edward R. Durant
Registered No. 75
(Month)
(Day)
1910
(Year)
Febuary
IO
At Home
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 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 Ilouse- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employcd, 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, peritoneum, etc., Carcinoma, Sur- 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 " (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.
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. Deathis 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
(No. Broken Road
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
79
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
11
| 5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Mario
6 DATE OF BIRTH Libril 2
(Month)
(Day)
(Ycar)
7 AGE
61 yrs.
6
mos.
6
ds.
of
min. ?
8 OCCUPATION )
(a) Trede, profession, or
particular kind of work
Jetivo Farmer
(b) General nature of industry. business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
Cis By am
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Chicliefert-
12 MAIDEN NAME
OF MOTHER
China Wanner
18 BIRTHPLACE OF MOTHER (State or country)
Lige D. H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
1.5 Byany
(Address)
16 File Oct: 11, 1910 Edward Y: Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Llet.
(Month)
1
(Day)
19!/0)
(Year)
17 HEREBY CERTIFY that I attended deceased from act. 1et. 1910 . to Oct. 8 1910
If LESS than
1 day, ....... hrs.
that I last saw him alive on
act. 8th
191 0,
and that death occurred, on the date stated above, at ..
9P.
m.
The CAUSE OF DEATH* was as follows :
Bronchial
asthma
(Duretion)
yrs.
mos.
ds.
Contributory
(SECONDARY) Schile
(Duration)
... yrs.
mos. ds.
amara toward.
M.D.
(Signed)
art. 1090
(Address)
* 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
In the
yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Haut Pond Cen
DATE OF BURIAL
(let 1)
19/10
20 UNDERTAKER
1
Heckler Pechan
ADDRESS
Chetrustun.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
238 Chelmsford
(City or town.)
2 FULL NAME
erde.
[If married or divorced woman or widow give maiden name, also name of husband.] z. @RESIDENCE
1829
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can bo 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, 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 bo indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, writo 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) ; Mcasles; 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 strcet, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(OTTE OR TOWN.)
FULL NAME
anequal Nelson
80
Registered No ..
Place of l
Westchelmsford Hours.
Date of 1 3 × 12.
.191 0
Residence
VetChelmsford NI ist.
Age 17
.. years .... /./.
.. months .........
.. days
STATISTICAL DETAILS
SEX
mali
COLOR
White.
SINGLE, MARRIED, WIDOWED,-OR DIVORCED
single
MAIDEN NAME t
HUSBAND'S NAME +
BIRTHPLACE #
NAME OF FATHER
Ungust Norton
BIRTHPLACE OF FATHER#
MAIDEN NAME OF MOTHER angus austin
BIRTHPLACE
OF MOTHER #
Suceden
OCCUPATION Stone Cutter.
INFORMANT § august nesten West Checkenford Massa
PLACE OF BURIAL OR REMOVAL I
DATE OF BURIAL
Oct. 19
191 0
UNDERTAKER
ADDRESS Westland 1Hlavi.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that-I attended, deceased during last illness, from. Left-13 .19/0 Soft-Det-12 910 to .....
that to the best of my knowledge and belief, death occurred on the my lar deg ~1. 8.30 date stated above, and that the CAUSE OF DEATH was as follows : am
Primary :
Typhoid fever
. (DURATION) 29
... DAY8
Contributory :
.. (DURATION). DAYS
(Signed).
I abarney
.M.D.
004. 12 19/0 (Address):
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Place of Death ? .. years. months days
Where was disease contracted, If not at place of death ?.
Filed Oct. 12 1910. Edward J. Robbins
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If in a Hospital or Institution, give its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
# State or country; also city, town or county, If known.
§ Name and address of person giving statistical detalis. Il Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
-
.
S
..
239
-
Death * S
Death
3 ...
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
(No. Highe ad avest. ; Ward)
240
(City or town.)
[if deeth occurred in a hospitel or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
1910 (Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was" as follows :
(Duretion)
ds
9 BIRTHPLACE
(State or country)
Chelmsford
10 NAME OF FATHER
Harold a. Idue
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Camada
12 MAIDEN NAME OF MOTHER
12 the Guardian
13 BIRTHPLACE OF MOTHER (State or country) ova
catia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(informant)
Harold a Idue
(Address)
no Chelmsford
15 Oct. 17, 1910 Edward Richting
- REGISTRAR
Contributory .. (SECONDARY)
(Duration) .yrs. .. mos.
.ds.
(Signed)
al. 169
1910 (Address)
M.D.
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At plece
In the
of death
yrs.
mos.
ds.
State ....
.. yrs.
mos.
ds
Where was disease contracted, if not at place of death ?. Former or usual residence
2 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Riverside bemesting Oct 17 20 Chelmsford
191.0
ADDRESS
20 UNDERTAKER
Geo. W. Ideally 79 Branch
important. See instructions on back of certificate.
Trez
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE id (
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
ingle
6 DATE OF BIRTH July 7 (Month)
7 AGE
If LESS than i day ......... hrs.
or ......... min. ?
8 OCCUPATION (a) Trede, profession, or particular kind of work.
L yrs. 9 ds.
1 mos.
one
(b) General nature of industry, business, or establishment in which employed (or employer) ...
1910 17
(Day)
(Year)
MARGIN RESERVED FOR BINDING
3 SEX
4 COLOR OR RACE
Female White
Registered No.
81
16
....
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 eachı 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.
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