USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 15
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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 usc of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- neumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
4
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of. (name origin : "Cancer" is less definite ; avoid use of "Tumor" for malignant ncoplasms) ; 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," "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 tho 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 strect, or one supposed to be duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dcad, etc.
ld state
PHYSICIAN
N. B. T.Every, item of information should be carefully supplied. AGE should be stated EXACT CAUSE OF DEATH in plain terms, so that it may be properly classified. Wact FAolin Af OCCU,Upis ver
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chefrefund Maco (No.
l'orthen
St. :.
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
S, SEX
4 COLOR OR RACE
11. Juste
& SINGLE,
MARRIED,
OR DIVORCED .
(Write the word)
6 DATE OF BIRTH
2
1826
17
(Month)
(Day)
(Year)
7 AGE
If LESS than ! day, hrs.
84
yrs.
8
. mor: 58
ds.
or ....... min. ?
8 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)
Monitoru, D.H.
PARENTS
12 MAIDEN NAME
OF MOTHER
Elkins
Revis
13 BIRTHPLACE OF MOTHER (State or country) stronaliên, N.H
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Carrie Ellensé-
(Address)
Cheline faid.
15 Filed. Jan. 2. 191 Edward Y. Raffin
/ REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec. 30t
19!0
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
200 /st, 1910, to Deci 30
_, 191 0 .
that I last saw him alive on
Die, 30
, 1910,
and that death occurred, on the date stated above, at 6 .m.
The CAUSE OF DEATH* was as follows :
Senile
(Duration)
yrs.
mos.
....
ds.
Contributory
(SECONDARY)
mos.
ds.
(Signed)
...... ... (Duration).
aman toward
M.D.
De, 30, 190 (Address)
Chumustard.
* 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
Chefrefund. Mars. Jan. 2, 1991
20 UNDERTAKER
Walter Pechan
ADDRESS
Cheline fort.
VITH UNFADING INK- THIS IS A PERMANENT RECORD.
MARC. RESERVED FOR BINDING
WRITE PLAIN
important. See instructions on back of certificate.
....
10 NAME OF
FATHER
ELfucian Elliott
11 BIRTHPLACE OF FATHER (State or country) Forceler, N. H.
253
(City or town.)
2 FULL NAME [If married or divorced woman of widow give maiden name, also name of husband,} @RESIDENCE
Registered No.
94
HM O.
ADA O CERTIFICATE - CATHY
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples : (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 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, G. 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," nnqualified, is indefinite) ; Tuber-
Is of lungs, meninges, peritoneum, etc. Carcinoma, Sar- coma, etc., of
:191 . Mi HIMas an .. (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 .; 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 septicaemia," " PUERPERAL peritonitis," etc. State canse 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, E.c- 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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(No ....... Lowell Hospital
St. :.
Ward)
1 CTAll (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME ....
Emilie B. Howard
[If married or divorced woman or widow
give maiden name, also name of husband.] nee ...... Birkby ...
@RESIDENCE
Chelmsford
Mass.
.( Elbridge G. Howard
1
Registered No.
95
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word) Married
1 185817
(Day)
(Year)
If LESS than
I day, ........ hrs.
.ds.
or ........ min. ?
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ...
Elbridge C. Howard
1. vadimmar
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
December
14
1910
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
Dec 1
1910, to Dec
14
191 0
that I last saw her . alive on ... Dec. 14
191 0
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Uterine tumor
(Duration)
yrs.
mos.
ds.
Surgical Shock
Contributory ..
(SECONDARY)
(Duration)
... yrs.
mos.
ds.
(Signed)
C. E. Simpson
M.D.
Dec. 16
1910 (Address) Lowell Hosp.
* 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
3
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 Cemetery
DATE OF BURIAL
Dec 17 1930
7º UNDERTAKER
ADDRESS
33 Juin cell et,
254
1 PLACE OF DEATH
... Lowell
3 SEX
4 COLOR OR RACE
Female
White
6 DATE OF BIRTH
ADI
(Month)
7 AGE
& 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)
England
10 NAME OF
FATHER
James Birkby
11 BIRTHPLACE
OF FATHER
(State or country)
England
12 MAIDEN NAME
OF MOTHER
PARENTS
Martha Hartley
13 BIRTHPLACE
OF MOTHER
(State or country) England
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
52
.yrs. ....
8.
mos.
....
16 Filed Dec. 19- 191.0.
=
ST D CERT.
DEATH. 3040
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 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 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-
·
Elyes, petitollieum, ttes i'm vinham, 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 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 onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
Andrews Lives In. alexander addie 2. arlin. Job. 6.
averell Barbara
147
Boudreau George
allard abraham
149
Brown Frank P.
ashworth Christina
168
Wishof marion a
68
Adama Frances OS
184 Bisbir Sarah &
adance many 209
adama Hettie
218
Boyd Glendon E.
225
Beandette Joseph R. Barbour Virginia Bowden John
Bridgford Thomas
Bowden Sarah &
Bakker Sarah S.
Bent Sarah J.
A
C D
M Mc N 0 P Q R S T U V W Y Z
12 38 44
55 · E 58 F G H 94
97 115 118 121 127 154 165 ·2CH 247
I J K L
Austin Charles H.
arvidson Christian 239
atwood Elvira 243
16 66 137
Berry Starren Byam mary J. Burns Quan
Bruun Oluf
Courses alph Conser Stilliam Cook Jonathan B. Carlson Trenila Crawford arthur B. Cannon Julia
Clark Dorothy .
74 77
Curry Catherine 71. book George H 138
Coburn Mary E.
15% 169
Conation John
Cornell Charles m. 176
Chapman Edward 178
Coffey many 179
Crockett Henry b. 199
Clemente Robert. I. 202
Cole Clara M. 206 Cassidy Gertrude M. 230
Cummings Emma E. 233
18 19 35
40
42 51
De La Haye Elias Fi 220
Derbyshire 244
Divine Many as
28
DEmer marle ? 37 Jaar William@mer Donglass Martha B. 171
Dickinson Elvira S. 48
Colcon Herbert H.
56
Emery Bessie 2. Emery Christiania Emerson Eliza Same Elliott amelia Emerson George &. 181
Exsiembre Martha a 186
9. 49 128 155
Fletcher Martha lane 20
Flodin Hannah m. 22 24
Fillmore Edmar Frees Eliga
Fitzpatrick Robert P.
Finnegan Margaut B.
Fletcher Franny
Filemmings Howard B. 87 Ferris William &. 164
Finnegan
172
26 E 36 F
Ž/ G 86
H
I J K L M Mc N 0 P Q R S T
U V W Y Z
Grover amme Gookin Rose H. Fraichen Gandette Joseph O. R.
Graham Hugh P. Glidden Jawline Gould Clarissa
Grady millicent ann
Gunston Etta H.
Gagnon Lauriei 159
Greenleaf Charles H! 189
Grady Josephine B. 190
Greenwood Miriam H. 23.1
100 102 124 156
Hallett Sarah P. Holland Steffen Haley John C. Hool William H. Holgate Barbara 6. Hoffe Johor Chick
Hogan William
Hunt Reuben J.
Hogan Margaret
Harrington Mary 13/ 146
Hoeffel marcus J
Half Edwin C. 167 Hulslander agnes & 1885
Hildreth Elmer & 214
52 64 76
78 95
Hall Effic a. Harding arm Harper Hourand
2 23 25 31
33 47 88 96 106 1.87 109
Ingham Large a. 135
Johnson Carl a. Johnson Mary" . . 99. - Johnson arthur Gillian
105 Johnson Paul ? 152
Mosselvan Mallace C. 232
8
L M Mc N 0 P Q R S T
U V W Y Z
Knowlton addie C. Kenniston Francie a. Kelley Georgianna a. Rearna- Edward Knowlton Herman L. Kinch PatriciaC. Knox David 7.
14 21 30 46 104
Le Marinel amelia G. 1 Lawler Thomas 39 61 75
Larkin John J. S. Lomax
Lakin Fred Co.
90
132
242
Leclaire Lillian Lavoie Roce
103
Lyons Charles
Lowcroft mary
Lechey Helena. Le dic Joe
Loucroft
Loncraft Charles
Luke Caroline 71. 180
Lavine Chietina C. 182
Lindsay George a. 198
L'Heureux Olive B. 212
Leboeuf Michael
235
m. maraton Robert marchal freth
224 237
1081 125 130 134 160 162
Martin Ellen F. mellin CynthiaM. miller arvila moore. Moore Sophia M.
Miner James M.
more Robert
120
nº Chure George H.
Mallalien Frederick
Marchall
150
moore James W.
Im Brath alice manning William
meagher John J. melvin Emma E.
miner Le. VV.
naylor Rita Hazel
85
98
Planglor mary It. Nichols Beatrice. 110 140 Nelson Svan Norton arthur S. 194
Naylor Beatrice 197 nystrom Walter S. 201
Mable Grace 216
15 32 53. 79 81 92
in Kale Philippe 3
Mccarthy Francis 8. 6
McDonough Mary 6. 10 Mckinley John 67
83 In brath MaryE.
Mc Connell Elizabeth 116 Mc Chance GeorgeH. 133
In Grath Mark
136
133 141
Mc Enancy Ruth a. 139
Mckeon John W. 163 In' Cabe Margaret 166
151
161 M°Connell Stewart M. 175
174 HP Grath Francie B. 200 M Clure Bridget I. 207 3 Nutty Catherine 208 211
185 203 M 2/3 MC N 0 P Q R S T U V W Y Z
Osterhout Pose 6. Orhana Margareta. O'Connell Margaret
Perham Perley P. 17
4
7 Perham Emeline a. 43
80 Plummer Charles a. 57
Perham Hannah F. 84
Parkhurst Martha Joner 89
Pehin Peter
126
Pharche anna M. 129 Parku Edward +. 14.4 Paasche Emmam. 177
Parkhurst Octavia L 196
Patterson William 21. 215
Park Sarah . 2.45
59
Aydingsvard Unna M. 11 Rogue Bernice . 54 Hobert Celphone 113 Lobbing Lucie B. 171 Sigley Royal S. 191
Ryan Gerald . 227
R S T
U V W Y Z
Quinn anna G. Quigley Josephine F . 122
1
7
1
Smith annat St. Cyr. Leo Shea Richard M.
Sprague Clarence It.
Stearns Dan. F.
Stafford Orange H.
Sheldon arthur N.
Stanley Stallace
93
Valbot 210
Longburg Petronelle 219
Soucy melina
114
Sheehan Andrew Smith Carrie 9.
123 158
Scribner Ruth m. Sargent Rebeccal. Smith Hannah F.
Stevens Hannah
193
205
221
222
Small Sarah 2, Smith Bridget 223
Sargent Sophia &. 226
Smith Usareff 13. 229
Smith Halte 234 Stiles 238
Sanford Elimina 6.
246
Thomas James 5
27 Thomas Mary 71. 4.5 72
50 Vuck amy In.
62 Fromblay Joseph a. 2. 14.2
63 Tremblay Harris 145
65
Talbot Lenge E. 148
82 Jake Winnifred V. 204
Sheehan Thomas
101
119
173
192
Simpson Cheater? Smith amara
13
Vickery
143 Vaillant Eugene C. 228
U V W Y
Z
Hermana Marian n. 236.
29 34 41 60 69 73
right Harry 2. Harren moses O. Harley Frederick C. Hard Hortense 8.
Apitney Sylvia a. Naturhouse Sety Theler Bridge Seeley John 6. Hinch Marcus A.
112
153
Dela Viola Lyda
183
Warren Julia 8 187
Talker 195
White James H. 217 Hordward Merrill 240
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. Groton Road.
St. :
North Chelmsford. Ward) (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
FULL NAME. Amelia G. Le Marinel.
[If married or divorced woman or widow give maiden name, also name of husband.} @RESIDENCE Groton Road.
Amelia Greeley. John Se Marinel Sr.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female,
4 COLOR OR RACE
White.
5 SINGLE,
MARRIED,
WIDOWED Named
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
May
(Month)
27
(Day)
18:42
(Year)
7 AGE
If LESS than ! day ......... hrs.
68
. yrs.
7
mos.
10
ds
or ........ min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work.
At Home.
The CAUSE OF DEATH* was as follows :
Carcinania
(abdominal)
(Duration)
yrs.
... mos.
ds.
Contributory
(SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
7 E Vaney
M.D.
, 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
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
Riverside Cemetery
Nr. Chelmsford.
DATE OF BURIAL
Jan, 8, 191
(Address) Nr. Chelmsford.
16 Filed Jan. 8, 1911 Edward J. Robbins
REGISTRAR
16 DATE OF DEATH
Jan.
(Month?)
(Day)
6.
.
1911
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Pary 3
1911 to tary 6
.. ,
191L.,
that I last saw her alive on
191./ ,
and that death occurred, on the date stated above, at 6.400.m.
(b) General nature of industry, business, or establishment in which employed ( or employer) ..
At Home.
9 BIRTHPLACE
(State or country)
Jersey Island. Englands
10 NAME OF
FATHER
Philip Greeley
PARENTS
11 BIRTHPLACE
OF FATHER
State or
1) Jersey deland. England
12 MAIDEN NAME
OF MOTHER
Nancy Pennwell.
13 BIRTHPLACE
OF MOTHER
(State or country)
Jersey Islands England.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
John Le Marinel Pr.
20 UNDERTAKER
GromHealey.
ADDRESS
79 Branch 8%.
MARGIN RESERVED FOR BINDING
important. See instructions on back of certificate.
8
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, ete. 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 inay 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, ete. 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 school or At home. Care should be taken to report specifically the occupations of persons engaged in domestie service for wages, as Servant, Cook, Ilousemaid, 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 eausation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- oncumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
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culosis of lungs, meninges, peritonaeum, ete., Carcinoma, Sar- 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, ete. 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 mero 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 causo for which surgical operation was undertaken.
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