USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 14
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Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (tho 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 le 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.
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
no Chemsford
(No
no chemsfords
„St. :
mary 9. Burlingour
Edward
Registered No.
90
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX female
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
6 DATE OF BIRTH
1
(Month)
(Day)
(Year)
7 AGE
50
.... yrs.
mos.
ds.
or ........ min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
at Home
(b) General nature of industry, business, or establishment in which employed (or employer) ....
9 BIRTHPLACE (State or country) Halifax n. S.
10 NAME OF
FATHER
Hamis Lestley
PARENTS
12 MAIDEN NAME OF MOTHER
Mary Meagher.
13 BIRTHPLACE OF MOTHER (State or country)
Leland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
no charge bad min
16
Filed .. 191
.........
REGISTRAR
(Duration)
.yrs.
mos.
14
ds.
Contributory
Effeción poleunter >
(SECONDARY)
(Duration)
yrs.
mos.
....
ds.
JE Varner
M.D.
(Signed)
Dee f
.. ,
1910
(Address).
2. Chelverfeil,
* 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
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 ....
19 PLACE OF, BURIAL OR REMOVAL Edson
DATE OF BURIAL
Jeell
191.0
20 UNDERTAKER
ADDRESS
Thomas yll Dermott Jo yorbank
24.9
(City or town.)
Ward)
[If death occurred in a ho al or institution, givej 14 NAME instead of sitre:t and number.]
'FULL NAME [If married or divorced woman or window give maiden name, also name of husband.] @RESIDENCE no chemsford
16 DATE OF DEATH
lee
8
1910
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
nor 251
1910, to
Dee 8
1910.
that i last saw h ~~ alive on
Dee 8
1918.
and that death occurred, on the date stated above, at 2/Jem.
The CAUSE OF DEATH* was as follows :
Preumon
via
11 BIRTHPLACE OF FATHER (State or country) Ireland
Husband.
If LESS than
1 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) 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. Womeu 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 giveu 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," "Weakuess," 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 uudertaken.
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.
0
BIN
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMAN
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 Gast Thelines Ford IN
Jord (No
St. ;
Ward)
250 Chelmsford .(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
Female
4 COLOR QR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
1808:
(Year)
7 AGE
98, .yrs. mos.
ds.
Or ........ min. ?
& OCCUPATION (a) Trade, profession, or particular kind of work. at Home
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE (State or country)
Ireland,
10 NAME OF
FATHER
Michael Sullivan
11 BIRTHPLACE OF FATHER (State or country)
Queland.
12 MAIDEN NAME OF MOTHER Catherine Sullivan
13 BIRTHPLACE OF MOTHER (State or country) Geland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Robert Thinkwin
(Address)
gast Chilunsford
15 File DEc.10.190@dmand×1offline
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
DEC !.
(Month)
(Day)
1910
(Year)
I HEREBY CERTIFY that I attended deceased from
191.
., to
191
that | last saw h.
alive on
191
630
and that death occurred, on the date stated above, at 6 com.
The CAUSE OF DEATH* was as follows :
Service
Aguil of Board
ofHealth
(Duration)
yrs.
mos.
Contributory .. (SECONDARY)
(Duration)
mos
Auchunte, Icoloria
1
M.D.
(Signed)
... yrs.
D&c. 10,, 1910 (Address)
Chelmsford
* 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 ?. .... usual residence .. Former or
19 PLACE OF BURIAL OR REMOVAL LOQUE DATE OF BURIAL St. Patrick Cia Del. 12. 1910
ADDRESS
20 UNDERTAKER
Las H. No NEuna deswell Mars
9
6 DATE OF BIRTH
(Month)
(Day)
Catherine alouerey
2 FULL NAME [If married or divorced woman or widow give maiden name, also pame of husband.f. @RESIDENCE Coast Chelunsford Mars.
Catherine Sullivan Quali Julcu downe 0 Registered No. 9, y
).
ESERVED F
PARENTS
If LESS than
1 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) 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 be indicated thus: Farmer (rctired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Namc, 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) ; Tubcr-
F
culosis of lungs, meninges, peritonaeum, 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 disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (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," "Uraenia," "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 dcad, etc
L
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 Saude Chelinstant. (No
St. :
Ward)
(City or town.) Elf death occurred in a hospital or institution, give its NAME Instead of street and number.]
Mary Persis Byam
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] Daniel P By am @RESIDENCE Souchi Chelmsford
Registered No.
92
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
6 DATE OF BIRTH
July
(Month)
16
(Day)
1853 17
(Year)
7 AGE
7
..... yrs. .
4 mos.
25
ds.
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)
Boxlow, mass.
PARENTS
12 MAIDEN NAME
OF MOTHER
Nancy K. Wetherbee
13 BIRTHPLACE
OF MOTHER
(State or country)
Box low. mass.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(informant) _.
Mrs. E.T. Parklet (laughter)
(Address)
Chelmsford. mais
15 Filed De, 14 1910 Edward& Robbing
REGISTRAR
(Duration)
... yrs.
mos.
ds.
Contributory
Chronic Brights Provare
(SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
OV. Wells
...
M.D.
Dec. 12
Westford, Maso
... , 1911) (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
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.
19 PLACE OF BURIAL OR REMOVAL Hart Pound Cen.
DATE OF BURIAL
Dec. 14
1910
20 UNDERTAKER
Waller Perham
ADDRESS
Cheliusfund.
"- THIS IS A PERMANENT RECORD.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADIN
important. See instructions on back of certificate.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
December
11
(Month)
(Day)
19!0
(Year)
I HEREBY CERTIFY that I attended deceased from
May 11, 1910, to.
DEC-11
....... , 191.0 ,
If LESS than
1 day, .....
hrs.
that I last saw he alive on.
DEC. 10,
1916,
and that death occurred, on the date stated above, at 8 a.m.
Or ....... min. ?
The CAUSE OF DEATH* was as follows :
Chronic Valinear Disease.
of Heart (aartic)
10 NAME OF
FATHER
andrew Wetherbee
11 BIRTHPLACE
OF FATHER
(State or country)
Boxlow. Mais.
1 251
· ЗЯ001" Тизидмс-
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, Loeo- 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 - Coul 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 Ilousewife, Housework, or At home, and children, not gain- fully employed, as At sehool 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 (tho only definite synonym is " Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
УЈИНАЈА З"
eulosis of lungs, meninges, peritoneum, 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 .; Broneho-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. 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.
EXACTLY. PHYSICIA + statement .of-occur
assifie.
CAUSE OF DEATH in plain terms, so that i. N. B. - Every item of information should be careful: important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Woodstock
VT
12 MAIDEN NAME
OF MOTHER
Hannah
Butts
13 BIRTHPLACE
OF MOTHER
(State or country)
Vermont
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) fol
Sa Whitman
(Daughter )
(Address)
Chelmsford mass.
15 Filed. Dec. 15/ 1910 Edward Se Rabbin , REGISTRAR
.
6 DATE OF BIRTH
10
I826
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day, ... . hrs.
84
.yrs.
5
mos.
ds.
or ........ min. ?
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Malignant disease of
vulva vagina and wettig
mos.
ds.
probables epitheliowa.
(Duration) 2 yrs.
yrs. +
Contributory .. (SECONDARY) 1
(Duration)
yrs.
mos. ds.
Acting, Scoluna
M.D.
(Signed)
DEc. 13, 19"
191C. (Address).
Chelunsford, Mac.
* 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
Edson
Cemetery
DATE OF BURIAL
Dec 15
1910
20 UNDERTAKER
6. m. Young
ADDRESS
33 Prescott of
shc
I PLACE OF DEATH Chelmsford Mass
(No.
St.
Idris
F. Whitney
‘FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford
Mass
Idris F. Richardson. Alvah S. Whitney
93
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female
White
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
Widow
16 DATE OF DEATH
December
I2.
191.0
....
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
.
For about 2 years-
1. 191.
to
NEC, 11 1910
that I last saw her alive on
, 1910
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
At
Home
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Woodstock VI
10 NAME OF
FATHER
William Richardson
252
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Chelmsford Ward) (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
MEDICAL CERTIFICATE OF DEATH
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 thereforc 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 "Laborcr," "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, 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.
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