USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 13
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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 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," 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.
1
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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
86
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX Female
4 COLOR OR RACE
5 SINGLE,
-MARRIED,
WIDOWED,
Single
OR DIVORCED
(Write the word)
6 DATE OF BIRTH New 20th 1910
(Month)
(Day)
1
(Year)
7 AGE
If LESS than 1 day, . hrs.
yrs. mos.
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)
10 NAME OF
FATHER
Field ball Silk
PARENTS
11 BIRTHPLACE OF FATHER (State or country) England
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country} Billenco
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Fred lell Sille
(Address)
15 Filed Mar. 22. 1910 Edward & Robbing
REGISTRAR
16 DATE OF DEATH
20020
(Month)
(Day)
19:0
(Year)
17 I HEREBY CERTIFY that I attended deceased from
200 2000.
to
191.
....
that I last saw h'S
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
till com
(Duration)
.yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration) .
yrs.
mos.
ds.
(Sighed)
nov2, 190
(Address)
/145 memurudes
* If death followed injury or violence the certificate of deathemust 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
DATE OF BURIAL
Neu 29
1910
245
1 PLACE OF DEATH Chelmeling
St. :
Ward)
Child of
.......
Field and Harnett Silk
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
MARGIN RESERVED FOR BINDING
-
20 UNDERTAKER LA Wencheck So well
M.D.
... .
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 iu 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 ouly 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 roturn " 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 acceptod term for the same disease. Examples: Cerebro-spinal fever (tho 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- 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 .; Broneho-pneumonia (secondary), 10 ds. Never report more symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility ". ("Congenital," "Senilo," 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 tho 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 one supposed to be due to Alcoholismi, etc.
4. Deaths under circumstances unknown, as A person found dead, 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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford
(No.
Tracks BIM. RR
St.
246 Lowall (City or town.)
...
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
82 Commun Ir.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
mali
4 COLOR QR RACE
That
5 SINGLE
MARRIED
WIDOWED
OR-DIVORCED
(Write the word)
Married
6 DATE OF BIRTH
-
(Month)
(Day)
7 AGE
If LESS than 1 day, .. .... hrs.
ds.
or ........ min. ?
8 OCCUPATION Stationen Vireman
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
Cotton mill
(Duration)
.yrs.
mos. ds.
9 BIRTHPLACE
(State or country)
Contributory
(SECONDARY)
.(Duration)
. ...
yrs.
ds.
Alterar, ... , M.D.
160 Merkmack I
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.
16 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
„ mos.
ds.
In the
State ...
yrs.
mos.
ds.
Where was disease contracted, if not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL 1 St. Patruje Cemetery
DATE OF BURIAL
IN 26,
1910
(Address)
F2 Commun VA
15 Filed Nov. 25, 1910 Oderand J. Rolling
REGISTRAR
16 DATE OF DEATH
24
(Month)
(Day)
1910 (Year)
1866 17 I HEREBY CERTIFY that I have investigated the (Year) death of the deceased. The CAUSE OF DEATH* was_as follows : acciden (Both, RR) Struck by Train
Multiple Traumatisme
10 NAME OF FATHER John Brennan
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Queland
12 MAIDEN NAME OF MOTHER Budget Nome,
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Ifil
(Informant)
Mis Cillen Newman The
20 UNDERTAKER
ADDRESS
....
James Brennan
Ward)
Registered No.
87
MARGIN RESERVED FOR BINDING
44
yrs.
mos.
(Signed)
www. 25.
1910 (Address).
... mos.
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 fircman, 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, 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, Houscwork, 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 fcver (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," 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 strcet, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dcad, 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
important. See instructions on back of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Zirvell maro.
553 .Aricaduran
St. :
Ward)
Ollen bankett,
2 FULL NAME
{If married or divorced woman or widow
give maiden name, also name of husband.] ..
ne Jaune (Thomas (linkitt)
@RESIDENCE
Registered No.
7/12
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Ternale
4 COLOR OR RACE
White
-
5 SINGLE
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
-
Married
« DATE OF BIRTH
Cina
(Month)/
(Day)
(Year)
7 AGE
15
yrs.
3
mos.
.ds.
or ........ min. ?
8 OCCUPATION
at Hame
(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)
fullind.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Ellen Brans.
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland.
14 THE ABOVE IS TRUE TO, THE BEST OF MY KNOWLEDGE
(Informant)
Busband
(Address)
15 D.I.c. 2. 19 196
Filed.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
72020 23
191( to
: 1910.
m.
that I last saw het alive on
.... 1915,
and that death occurred, on the date stated above, at 12
The CAUSE OF DEATH* was as follows :
1
.... (Duration)
.. yrt.
nosds.
Contributory.
Listeria Acherasco
(SECONDARY)
(Duration) ..
.. yrs."
--
mos. .
ds.
M.D.
(Signed)
Dec 20.
1915 (Address) is Civile
21
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
16 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
Dec . 1910
20 UNDERTAKER
Peter Diary
ADDRESS
134 Incisfest 21.
247
Ionell
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
888
23
191 ()
(Month)
(Day)
(Year)
12
1845
17
If LESS than
I day, ..
hrs.
10 NAME OF
FATHER
Bains
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
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. Tbe 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, peritoneum, etc., Car oma, Sur- 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 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 tho 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.
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.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Westfind.
12 MAIDEN NAME
OF MOTHER-
Quilla Bostwick
13 BIRTHPLACE
OF MOTHER
(State or country)
Franconia N.M.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Uno Ch akamois
(Address)
So Chelmsford
15 Filed. 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
lec
2
(Mouth)
(Day)
1900
(Year)
I HEREBY CERTIFY that I attended deceased from
Aug. 11
., 1910, to
nov. 25, 190.
....
that I last saw him alive on.
nov.25
, 1910,
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows : Arterio schrocii, Enlarged strait. Disease of Lift aper of
(Duration)
.... yrs.
.
mos. ds.
Contributory
(SECONDARY)
(Duration)
.. yrs.
(Signed)
Autumn 9. Scafona
,
mos.
ds.
M.D.
DEc. 4
1910 (Address)
Chehuxford, 2020.
* If death followed injury or violence the certifieate 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 Hart Land Curry. Soude Chelinstead
20 UNDERTAKER
Wallin Pechan
ADDRESS
Chelmsford.
3 SEX
4 COLOR OR RACE
w
5 SINGLE.
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH
Mar.
10
1848
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day, ....... hrs.
yrs.
×
mos.
2 Zds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work farmer
(b) General nature of industry, business, or establishment in which employed (or employer) ...
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massarhutsetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford, Mass. (No
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Herbert alongo
Sweetie
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE I heleusted.
Registered No.
89
PERSONAL AND STATISTICAL PARTICULARS
248
(City or town.)
DATE OF BURIAL
Dec. 4
1910
S
e
S
9 BIRTHPLACE (State or country) Weatherd Mans
10 NAME OF
FATHER
Lorenzo Jurelação
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 bo 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 thorefore 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 tho 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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