USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 24
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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.
COMMONWEALTH OF MASSACHUSETTS.
RETURN OF A DEATH-1911.
CITY OF BOSTON.
FULL NAME Moses A Warren
Registered No .. 5322
Place of Death )
Boston
and Residence S
May 31
53
8
26
Date of Death
1911.
Age
years
months
days.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
M
W
M
Maiden Name.
Husband's Name.
Freedom, Me.
Birthplace
Name of
Alfred Warren
Father
Birthplace of Father.
Freedom, Me.
Maiden Name Rebecca Libby
of Mother
Birthplace of Mother ..
(Signed)
B Hollings
M. D.
May 31 1911
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents. In hospital 8 days
Place of Burial or removal ..
Cambridge"Mt. Auburn Crem. "
Usual Residence
North Chelmsford, Mass.
June. 3
Filed
1911
A true copy.
Attest :
Enmblement
Registrar.
MARGIN RESERVED FOR BINDING.
PHYSICIAN'S CERTIFICATE.
| HEREBY CERTIFY that I attended deceased during last illness,
from 1911, to. .1911, that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows:
STRAR'S
ASIGUT P (Duration)
Chr.Hepatitis
MSIFLIALO
BOSTO
MASS .
Contributory : {
Chr. Cong.of spleen
(Duration)
----- Me.
School master
Occupation
Informant.
CITY. REG
- BOSTONTA" CONDITA A
ATA A. 1822.
ISREGI 183D. WE DONATA A
Undertaker.
C M Young
Lowell
34
lass. Gen . Hospt.
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
I PLACE OF DEATH
Jonathan B, Le cute
2 FULL NAME [If married or divorced woman or widow, give maiden name, also name of husband.] @RESIDENCE Valehelmehvid
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,(
OR DIVORCED
( Write the word)
Widlinea
6 DATE OF BIRTH ct/4 23 rd 1825, (Month) (Day) (Year)
7 AGE
If LESS than ! day ......... hrs ..
86, yrs. 1 m
mos.
/4 rds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
tengo Humecter
1
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Wakefield w XX
PARENTS
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country,
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address) Nothelfail
15 Filed June 10, 1911 Edward X. Robbing
/ REGISTRAR
16 DATE OF DEATH
8
191/
(Month)
(Day)
( Year)
17
I HEREBY CERTIFY that I attended deceased from
June 2, 191
June 8
to fun
1911
that I last saw him, alive on
191/.
and that death occurred, on the date stated above, at
m
The CAUSE OF DEATH* was as follows :
acute cyclitis
( wok selection of wine)
(Duration)
.yrs.
.mos.
ds.
7
Contributory
Is Jene troffy of prostate
(SECONDARY)
(Duration).
(Signed)
JE Varney
M.D.
19/
* 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
que 10-
191
20 UNDERTAKER/
ADDRESS
35
(City or town.)
Registered No.
35
MEDICAL CERTIFICATE OF DEATH
.....
10 NAME OF
FATHER
Bertani leute
11 BIRTHPLACE OF FATHER (State or country)
mos . ds.
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 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) 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 minc, 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 Ilousewife, Housework, or At home, and children, not gain- fully employed, as At schoolor 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.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
36 Chelmsford Ward) (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. :
Robert P. Fitzpatrick
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Eart Chelmsford, IVac). Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jung
.
9
191)
(Month)
(Day)
(Year)
6 DATE OF BIRTH
March
28
(Month)
(Day)
(Year)'
.... If LESS than
1 day ......... hrs.
39 ... yrs. 2 mos. 12 ds.
or ......... min. ?
10 NAME OF
FATHER
Hugh Fitzpatrick
11 BIRTHPLACE
OF FATHER
(State or country)
Canada
12 MAIDEN NAME
OF MOTHER(
Gathering Grant
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
barril Fetapatrick
(Address) Eait Callmelord
16 File June 11, 1911 Edward . Robbins
/REGISTRAR
te
=
to
=
are
e."
ond.
im-
SIDs);
ease;
1, Sar-
s less
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
1 PLACE OF DEATH Eart Chelmsford .. (No 3 SEX 4 COLOR OR RACE malf 11 hits 7 AGE 8 OCCUPATION (a) Trade, profession, or (b) General nature of industry, business, or establishment in which employed (or employer). 9 BIRTHPLACE (State or country) Canada PARENTS 13 BIRTHPLACE OF MOTHER (State or country) Canada 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 particular kind of work 1 alene,
15 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
-
(Write the word)
1.872
I HEREBY CERTIFY that
attended deceased from
1 mere 7 th
191 /
to
....
that I last saw h.m. alive on
.... , 191./,
-
and that death occurred, on the date stated above, at 4 Pm
The CAUSE OF DEATH* was as follows :
Phlimonary tubeculosis
(Duration)
make
Contributory
Primultral abscess-
0
ds.
....
(SECONDARY)
.(Duration).
yrs. 2
.mos.
(Signed)
M.D.
this 11-1911. (Address)
Jout Bilkrieg
* 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
DATE OF BURIAL
Edsonberneterie/Jung 11, 1911
20 UNDERTAKER
ADDRESS
Seom. Cartinarobo 24 Jackson St
MARGIN RESERVED FOR BINDING
36
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, 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) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," "Manager,""Dealer," ete., 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 Houscwife, 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 servico 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 rc- port " Typhoid pneumonia ") ; Lobar pneumonia, Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
eulosis 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 .; 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," ete. 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 Delima allard
13 BIRTHPLACE OF MOTHER (State or country)
-Granada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Forth Deres
(Address) auf Cheeuchund
15 led Jsme 9, 191) Edward S Ralthing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
June
9
1911
(Month)
(Day)
(Year)
6 DATE OF BIRTH
12
-
(Year)
7 AGE
10 yrs. 11
.mos.
.2%.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work
none
(b) General nature of industry, business, or establishment in which employed (or employer) ...
º BIRTHPLACE
(State or country)
(Duration) 2
.yrs.
.. mos.
ds.
Contributory
Pulmonary Laryngitis
16
(SECONDARY)
(Duration) 3
.yrs.
mos.
ds.
(Signed)
Frank R. Brody
M.D.
June 9, 1911 (Address) 52 Central St.
*If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
ds.
State
In the
yrs.
mos.
ds ...
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
.....
20 UNDERTAKER
37
.....
(City or town.) [If death occurred in a hospital or institution. give its NAME instead of street and number.]
0
Marie ElisabethDemens
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
North Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
0
(Month)
(Day)
.
on I HEREBY CERTIFY that | attended deceased from may1St, 1911, to. 191. ..... .
If LESS than
1 day .......
hrs.
that I last saw h CL alive on
may 1 st."
191 ... ),
-
and that death occurred, on the date stated above, at & A.m .
The CAUSE OF DEATH* was as follows :
Tubercular Laryngitis
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 North Cheiras forNo Food Garner St
Ward)
Registered No. 37
1
10 NAME OF
FATHER
Yough Derniers
11 BIRTHPLACE OF FATHER (State or country)
Barrada
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 torm 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 cxamples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia, Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, 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," "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, otc.
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.
St. :
Ward)
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
4 COLOR OR RACE
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Mariel
Hemale
White
ore
6
(Month)
(Day)
7 AGE
If LESS then I day, ........ hrs.
74
Vrs. 6
mos.
ds.
8
or ........ min. ?
8 OCCUPATION
(e) Trade, profession, or
particuler kind of work
athome
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Chelmsford
10 NAME OF
FATHER
Daniel Proctor
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Chelmsford
12 MAIDEN NAME
OF MOTHER
Betsy Parker
13 BIRTHPLACE
OF MOTHER
(State or country) Franceetrun n. H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs H.C. Breve
(Address)
Chalweford
16
Filed
June 15, 1911 Edward J. Robbing.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
14
(Month)
(Day)
191 /
(Year)
1836 17 I HEREBY CERTIFY that I attended deceased from (Year) May 16. 1911.
191
to
that | last saw h ..
alive on
May 16
....... , 191./ .
and that death occurred, on the date stated above, at ...
m.
The CAUSE OF DEATH*was as follows :
Valvular Ducase of Heart
.(Duration)
... yrs.
mos.
ds.
Contributory
(SECONDARY)
mos.
ds.
(Signed)
Arthur 9. Scobina
........ , M.D.
June 16 191 (Address).
Chelen ford-
* 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
Horafactor Com.
DATE OF BURIAL
June 16
191 1.
20 UNDERTAKER
ADDRESS
Chelmsford
38
Mary Jane Byam 2 FULL NAME. [If married or divorced woman of widow give maiden name, also name of musband.] @RESIDENCE Chelmsford
Registered No.
38
6 DATE OF BIRTH
MARGIN RESERVED FOR BINDING
.... yrs.
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 minc, 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-
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