USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 19
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37
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.
.
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
Chelefond
(No.
Billerica
St. ;
Ward)
Fif death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
addie Cornelia Knowallow
[If married or divoreed woman or widow
give maiden name, also name of husband.]
@RESIDENCE
lehelunsford.
Horace Knowlton
Registered No.
14
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
5
(Day)
19! /
(Year)
6 DATE OF BIRTH
May
29
(Month)
(Day)
18.52
17
(Year)
I HEREBY CERTIFY that I attended deceased from
190% to March S, 1911.
If LESS than
I day, .....
hrs.
that I last saw her alive on
March 5.
1917 ,
and that death occurred, on the date stated above, at 6:40m.
The CAUSE OF DEATH* was as follows :
Multipes Caramona-
about
(Duration) 3
.... yrs. ....
mos.
ds.
Contributory. (SECONDARY)
>(Duration)
.yrs.
mos.
ds.
(Signed)\
Actual, Scofina
M.D.
...
machs
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.
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
Westlaw Ceny Lowell . Mas. 8
191 /
20 UNDERTAKER
Waltin Pecham
ADDRESS
chelmsford
important. See instructions on back of certificate.
PARENTS
12 MAIDEN NAME
OF MOTHER
Charlotte L. Roque
13 BIRTHPLACE
OF MOTHER
(State or country)
Boston Mars.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ...
Mr. Horace Purullena
(Address)
Chelcustard,
S.P.
15 Filed Mas 6, 1911 Edward Rolling
REGISTRAR
5 SINGLE
MARRIED
WŁODWED,
( Write the word)
7 AGE
58
... yrs. ..
9
mos.
6
ds.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ...
House wife
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
try Stoddard N.H
10 NAME OF
FATHER
Celando Blodgett
11 BIRTHPLACE OF FATHER (State or country) utry Stoddard N.H
In the
14 Chelmsford ... (City or kówn.)
MARGIN RESERVED FOR BINDING
3 SEX
4
4 COLOR OR RACE
White
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 Ilousc- kcepers 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, 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 discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL 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.
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
12 MAIDEN NAME OF MOTHER
Elizabeth Pratt
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed Man 10, 1911 Edward Y Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Mich.
8%
19 !!
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
191
to
mich. 8th
1911
that I last saw her alive on.
mich, 8ª
191)
and that death occurred, on the date stated above, at ... P. m.
The CAUSE OF DEATH* was as follows :
Senile.
(Duration)
yrs.
mos. ds.
. ...
Contributory. (SECONDARY)
(Duration) .yrs.
mos. ds.
(Signed)
Amarastoward
... .
M.D.
Mich. 9th
1911
(Address).
Chelmsford Mari
* If death followed injury or violenee 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 Salisbury UT.
DATE OF BURIAL
March 1/ 1911
ADDRESS
20 UNDERTAKER
Walter terhow Chelmsford.
1
mere
Te,"
ite all
ER-
ate
ng
to
ad
Chelmsford 15
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Ellen Frances Martin
2 FULL NAME
{If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford mand
Drivey, Husband-Harvey 8 Marting
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Hemals
4 COLOR OR RACE white -
1 5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Midon
6 DATE OF BIRTH Harch 8 191
(Month)
Sept
(Day)
200
(Year)
1832
If LESS than
I day, hrs.
78 yrs. 5 mos. /1 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)
Salisbury VA.
10 NAME OF FATHER
Trueman Orwey
11 BIRTHPLACE OF FATHER (State or country)
Connecticut
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford (No
St. :
Ward)
Registered No.
15
7 AGE
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 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 None.
Statement of cause of death. - Name, first, the DISEASE ('AUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, 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," "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 deathis 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.
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 South Chelmsford (No.
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Lucy M. andrews.
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE So Chelmsford
Lucy M. Symmes: James E-andrew
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH March 11
(Month)
(Day)
1911 (Year)
17 I HEREBY CERTIFY that I attended deceased from 6.12, 1916 to. March 11. 1915,
I day, .. hrs. that I last saw her. alive on March 11, 1911.
and that death occurred, on the date stated above, at / 2/54m.
The CAUSE OF DEATH* was as follows : Phthisis Pulmonalis
chodefinite (Duration)
... yrs.
mos.
ds.
Contributory ....
(SECONDARY)
about
{Duration)
yrs.
.... mos.
ds.
(Signed)
Anten y Scafaria
M.D.
March 12, 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. ...
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 Hartford Love 80. Chalcoford
DATE OF BURIAL
Mar, 13
191 /
20 UNDERTAKER
Halten Porlamar
ADDRESS
Chelmsford
Sar-
less
ns);
ase ; nd-
ere
An-
Je, ER.
ite all
e," ate
ODS
Is,
val
ed
und
16 Chelmsford (City or town.)
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Beverly
12 MAIDEN NAME
OF MOTHER
almina Willy
13 BIRTHPLACE
OF MOTHER
(State or country)
mais
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
gas E. andrews
(Address)
16 Filed 2as, 13, 1911 Edward . Rolling
REGISTRAR
3 SEX
female
6 DATE OF BIRTH
+ COLOR OR RACE
white
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
6 1800 (Year)
(Month)
(Day)
7 AGE
60
yrs.
9
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) Lowell mans
7
10 NAME OF
FATHER
Henry Symme
If LESS than .....
Registered No. 16
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to 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 (rctired, 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 ") ; Lobar pneumonia, Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., C'arcinoma, 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 dcad, etc.
7 AGE PARENTS 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. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state -
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford
(No
St. :
17 Chelmsford Ward) (City Ør town.) [If death occurred in a hospital or institution, give its NAME insteed of street and number.]
Registered No. 17
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
white
5 SINGLE,
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
Married
6 DATE OF BIRTH
Nº 1823
/(Month)
(Day)
(Year)
If LESS then
[ day, ....... hrs.
87 yrs. 6
... yrs. ...
mos.
1
ds.
or ........ min. ?
S OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired (Farmer)
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Hilton Mit.
10 NAME OF
FATHER
Samuel P. Perham
11 BIRTHPLACE OF FATHER (State or country) Hilton N.H.
12 MAIDEN NAME
OF MOTHER
nancy Nichols
13 BIRTHPLACE
OF MOTHER
(State or country)
Bedford U.H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Chro tenham.
(Address) 30 EdenSt. Lowice
16 Filed mas. 18 1911 1) Edward & Politics
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Inch .
16th
-
191) (Year)
17 I HEREBY CERTIFY that I attended deceased from november- , 1911, to Mel 16th .... ,
., 1911, that I last saw him alive on. Mich 1 5th, 1911. and that death occurred, on the date stated above, at 4:30Pm. The CAUSE OF DEATH* was as follows : Paralyseo
(Duration)
mos. ds.
Contributory. (SECONDARY)
(Duration) .
.... yje.
mos.
ds.
Amara Howard
.
M.D.
...
(Signed)
Incl.18
.......
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
Hovetatt
- Como
20 UNDERTAKER
Halter Perham
ADDRESS
Chelmsford
ate
ER-
ge," bite all
re,"
pse,"" al,
‘s .;
ems);
lease ;
ond-
im-
bere An-
is less
1, Sur-
ed
DATE OF BURIAL
March 19, 1910
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
2 FULL NAME {If married or divorced woman oy widow give maiden name, also name of husband.] aRESIDENCE Chelmsford
Perley Putnay
Terham
(Month)
(Day)
yrs.
2
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 (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 saine 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-
culosis of lungs, meninges, peritonaeum, etc., C'arcinoma, 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 deatlı), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report inere 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.
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.