USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 12
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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 definito 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," etc. 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 determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head-homicide ; Poisoned by carbolic acid - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of " Contributory."
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 dcad, etc.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
1 PLACE OF DEATH
Chelmsford Mass ....... (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
3 SEX
4 COLOR OR RACE
Male
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
6 DATE OF BIRTH
August
25
I822 17
(Month)
(Day)
(Year)
7 AGE
88
yrs.
mos.
21 ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Charlestown Mass
10 NAME OF
FATHER
Isaac W/ Whitemore
PARENTS
11 BIRTHPLACE OF FATHER (State or country) England
12 MAIDEN NAME
OF MOTHER
Unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
unknown
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs
George W. Humphery
(Address)
Chelmsford Mass
16 Filed Oct. 19, 190 Edward Y Robbins
REGISTRAR
16 DATE OF DEATH
October
I6.
191 0
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from 04/418, 1910 to 191
... .
If LESS than
$
I day .......
hrs
that I last saw h Et. alive on
00/14
191.2
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Old age
(Duration) .. ... .. yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration) ds.
(Signed)
00117, 90 (Address) Lavill Mars
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.
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 Tewksbury Mass
DATE OF BURIAL
Oct 19
1910
ADDRESS
20 UNDERTAKER
b.m. Young 330
241
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Chelmsford
2 FULL NAME Isaac W. Whitemore [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford iass
Registered No.
82
MEDICAL CERTIFICATE OF DEATH
MARGIN RESERVED FOR BINDING
...
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, peritonacum, etc., Carcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronie 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, ctc.
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.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
3 SEX
7 AGE
73
(a) Trade, profession, or
particular kind of work.
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
important. See instructions on back of certificate.
(Address)
16
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
....
4 COLOR OR RACE
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Married
6 DATE OF BIRTH
Sept.
(Month)
10
(Day)
(Year)
If LESS than
1 day .....
hrs.
yrs.
mos.
"
ds.
or
min. ?
8 OCCUPATION Contractor
(b) General nature of industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
"Bridgewater Mare
10 NAME OF
FATHER
Leonard Gnene
11 BIRTHPLACE OF FATHER (State or country) -
marc
12 MAIDEN NAME
OF MOTHER
Sylvia While
man.
14 THE ABOVE YS TRUE TO THE BEST OF MY KNOWLEDGE
(Informa
Mys. a. G. Greene
Filed
Oct. 25 1910 Edward 9, Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Och.
21
(Montlı)
(Day)
1900)
(Year)
1839
17
1 HEREBY CERTIFY that I attended deceased from
art. 17"1
1910, to
Oct. 21
, 1910,
that I last saw him alive on.
act. 21
, 1910.
and that death occurred, on the date stated above, at.2. P.
. m.
The CAUSE OF DEATH* was as follows :
Cardiac Paralysis
(Duration) . ..... .. . yr$. ....
mos.
.. ds.
Contributory
acute indigestion
(Duration)
yrs.
mos.
4
ds.
(Signed)
Umara
Howard
M.D.
art. 25
.. ,
1910 (Address).
Chelmsford mars.
* 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
1910
20 UNDERTAKER
Wollen Puchar
ADDRESS
Chelingue.
242
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
Chelmsford
(No.
Centre
St. :
Ward)
(City of town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
alonzo
Gardner Greene
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Registered No.
83
PERSONAL AND STATISTICAL PARTICULARS
The Commonwealth of Massachusetts
all (SECONDARY)
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 fuetory. 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 110 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 ") ; Łobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
eulosis 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; 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 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATHA
2 FULL NAME anna Doris Su
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Registered No.
84
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Female White
5 SINGLE
MARRIED,
WIDOWED,“
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH
Sixt. 13 (Month) (Day)
1915
17
(Year)
7 AGE
If LESS than 1 day, ....... hrs.
yrs.
1
mos.
16
ds.
or ....... min. ?
& 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) Hillsboro NIH.
10 NAME OF FATHER
John Midell
11 BIRTHPLACE OF FATHER (State or country)
Boston Mass
12 MAIDEN NAME OF MOTHER
Bertha Lundgren
13 BIRTHPLACE OF MOTHER (State or country)
Surden
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
5/3 0 aurina et.
16 Filed Oct. 31 1910 Edward S. Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Oct. 29,
(Month)
(Day)
19:0-
(Year)
| HEREBY CERTIFY that I attended deceased from
191
....... , to
191.
,
·that I last saw h - alive on
191
,
and that death occurred, on the date stated above, at ..
m.
The CAUSE OF DEATH* was as follows :
Incuiation - Convulsions
(Duration) . ..... . ..... yrs.
mos.
ds.
Contributory (SECONDARY)
(Ogation) M.D. (Signed) Mutua C. Scoton agt. Bit Hull Oct 30, 90 (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.
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 Edson century
DATE OF BURIAL
Oct. 31. 1918
20 UNDERTAKER
Seo. M. Eastman slo
ADDRESS
24 Hacknout
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
243
(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.
....
PARENTS
4 COLOR OR RACE
St. :
: Ward)
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 cntcred as Ilousewife, 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 discase. Examples: Cerebro-spinal fevcr (the only : definite synonym is "Epidemic eerebro-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 usc of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronie 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," "Senilc," 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.
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
Chelmsford Mass
St. :
Ward)
244 Lamell (City or town.) [If deeth occurred in a hospltel or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
20
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
16 DATE OF BIRTH
6
(Month)
(Day)
(Year)
7 AGE
80 yrs. 5 mos.
ds.
....... min. ?
8 OCCUPATION
`(a) Trade, profession, or
particuler kind of work
at home
(b) Generel nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
brunch, Mas.
PARENTS
12 MAIDEN NAME OF MOTHER Mary Stamford
13 BIRTHPLACE OF MOTHER (State or country)
Ipswich, Mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Frank C.
VI
Trescott
(Address)
31 Sherwood St.
15 File Av. 11, 1910 Edward J. Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
hr.
(Month)
9,
(Day)
19! 0
(Year)
1830 17 1 HEREBY CERTIFY that I attended deceased from 1909, to.
If LESS than 1 day, ...... hrs. that I last saw ha alive on.
nov. 3
1910
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Valvular Grant Omen
and Senility.
.....
(Duration)
.. yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration)
yrs.
. mos.
ds.
(Signed)
1
M.D.
Autre, Scobma
.. 1916. (Address)
* If death followed injury or violence the certi out by the Medical Examiner.
ochinicio or d'un must be made
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
ds.
Stete
.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 Edson ametery
DATE OF BURIAL
nov. 11. 1
1910.
20 UNDERTAKER
ADDRESS
, G. Weinteck so Middr. St
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
(No)
Mary S. Tres
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Many 5 Servett James H. Tres cott
Registered No. 301
Sept 3
nov. 3.
, 1910,-
.....
10 NAME OF
FATHER
Choses Sewelt
Phases
HI BIRTHPLACE OF FATHER (State or country) Ipswich, Mas. Ipswich,
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) Automobilc 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 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 Nonc.
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