USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 26
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culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, ctc., 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 Alcoholismi, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
-
: . 1
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE
OF FATHER
State or country felice ford.
12 MAIDEN NAME
OF MOTHER
Lydia Detein
13 BIRTHPLACE OF MOTHER (State or country) Leacut, Mass.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mix, Florale
(Address)
Chelmsford, Mars.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
-
Widerand
.
6 DATE OF BIRTH
Let
15
1822
17
(Year)
I HEREBY CERTIFY that I attended deceased from
Ing 3
1911, to
que 4
191.
.... If LESS than
I day,
.. hrs.
that I last saw her alive on.
The 3
191 .. ] ,
and that death occurred, on the date/stated above, at 4 4.m.
The CAUSE OF DEATH* was as follows :
Chapluxe
... (Duration)
yrs.
mos.
.. ds.
Contributory
Senile
-
(SECONDARY)
(Duration)
... yrs.
(Signed)
masa toward.
mos. ds.
M.D.
July 6, 1911 (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.
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 torefaches cu.
DATE OF BURIAL
Jeely / 19/09
16 Filed .. July 7, 1911 Edward . Rolling
Chelmsford
1.3
(City or town.)
St. :.
Ward)
Fif death occurred in a hospital or institution, give its NAME instead of street and number.]
Emelina aunquebão
Tuhan
Telef P. Pechan
Registered No.
43
PERSONAL AND STATISTICAL PARTICULARS
-16 DATE OF DEATH
July
(Month)
(Day) (Year)
(Month)
(Day)
7 AGE
88
yrs. .
8.
mos .
19
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment In which employed (or employer).
9 BIRTHPLACE
(State or country)
Chelmsford -
10 NAME OF
FATHER
John Spaulding
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
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
.
20 UNDERTAKER
Walter Pechany
ADDRESS
Chelinefond
191.1
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 (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis ") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia, Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- comu, 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- posurc, 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.
1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH North Chelunsford(No. Udano
St. ;..
Ward)
(Cif or town.) The death occurred in a hospital or institution, give its NAME instead of street and number.]
2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
adamo Street
Registered No.
44
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Mal
4 COLOR QR RACE
that
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH
18.27
(Month)
(Day)
(Year)
If LESS than [ day ......... hrs.
ds.
Or ......... min. ?
8 OCCUPATION (a) Trade, profession, of particular kind of work.
Matchman Retired
(b) General nature of industry,
business, or establishment in
which employed (or employer).
Colton Mill
9 BIRTHPLACE
(State or country)
Guland
10 NAME OF
FATHER
hat Juni
PARENTS
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
Wieland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE andlan
nt) Med Que & Colon
(informant)
(Address)
adams Street
15
Filed July 8, 1911Edward Robbins 0
/ / REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
. July
4
(Month)
(Day)
.,
197
(Year)
17 I HEREBY CERTIFY that I attended deceased from
191
.,
to
X
that I last saw him alive on
.1917,
and that death occurred, on the date stated above, at 830 m.
The CAUSE OF DEATH* was as follows : Venuplegia
(Duration)
.. yrs.
.. mos.
ds.
Contributory.
(SECONDARY)
(Duration)
.. yrs.
mos.
.ds.
(Signed)
JE Vaney
M.D.
july 7, 1911 (Address)
n. Chebenford
* 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.
in the
ds.
State ....
yrs. ...
.. mos.
ds
Where was dlsease contracted, if not at place of death ?.
Former or usual residence
DATE OF BURIAL
19 PLACE OF BURIAL OR REMOVAL Rt. Palingo Cemetery
20 UNDERTAKER
ADDRESS
4.4
Cheveux ford.
MARGIN RESERVED FOR BINDING
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
important. See instructions on back of certificate.
11 BIRTHPLACE OF FATHER (State or country) Juland
Oreal
........
mos.
7 AGE F4 yrs.
-
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to each and every person, irrespectivo 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 enginecr, 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," 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 domestie 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 eccupation 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. - 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 "Epidemie 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: 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," cte.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," "Old age," "Shoek," "Uraemia," " Weakness," ete., 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. ctc.
4. Deaths under circumstances unknown, as A person found dead, etc.
1
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.
Mari1
Hefen
honvar
Mary H. Kendall.
. Registered No. 45
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
7,
4 COLOR OR RACE
W.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) drived
6 DATE OF BIRTH Dec 8
(Month)
(Day)
1843
(Year)
7 AGE
69
.yrs.
6
mos.
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 Halifax N.S.
PARENTS
II BIRTHPLACE OF FATHER (State or country) Halifax, N.S.
12 MAIDEN NAME
OF MOTHER
Hard Robertson
C
18 BIRTHPLACE
OF MOTHER
(State or country)
Halifax. N.S.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
mis Knadall
(Address)
16
Filed_ July 11, 191/ Cdiva 0
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
8ml
(Month)
(Day)
191/ (Year)
17
I HEREBY CERTIFY that I attended deceased from
May 3", 1911, to.
Jak 8
191 .1.
191.1
If LESS than
I day ....
hrs.
that I last saw her alive on
July 8
,
and that death occurred, on the date stated above, at.
... m.
The CAUSE OF DEATH* was as follows :
Pernicious anaemia
... (Duration)
1 yrs. 6
.yrs ..
mos.
ds.
Contributory.
nephritis
(SECONDARY)
(Duration)
1
yrs.
mos. ds
(Signed)
Camara toward
M.D.
Julia.
1911
(Address)
Chulin Ford, Mass.
* 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).
In the
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 Line Ridge Cem. July 11. 1
191.11
ADDRESS
20 UNDERTAKER
Walter Pechan Chelmsford.
(City or town.) Elf death occurred in a hospital or institution, give its NAME instead of streat and number.]
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
James
45 Chelmsford
St. :
Ward)
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
10 NAME OF
FATHER
rhy tmosall
ward Spotting
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 "Lahorer," "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- keepcrs who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gaiu- 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 he 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 defiuite ; 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," "Couvulsions," "Dehility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," " Marasmus," "Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can he 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 he referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused hy violeuce, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Suddeu deaths of persons not disahled 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
0
0
€
macre
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
1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE, OF DEATH
1 PLACE OF DEATH Chelen ford (No
2 durand learned
2FULL NAME [If married or divorced woman or widow give maiden name, also name of busband.] @RESIDENCE
Inham SI Chelwex ford
Registered No.
46
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Mal Ahits
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
Single
6 DATE OF BIRTH May (Monthı)
22
(Day)
1911
17
(Year)
7 AGE
If LESS than 1 day, hrs.
1 mos. 2 0 de
or ........ min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work
(b) General nature of industry. business, or establishment in which employed ( or employer) ...
9 BIRTHPLACE (State or country) Juul Masa
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (State or country)
InMy Mars
12 MAIDEN NAME OF MOTHER anna Unuth
13 BIRTHPLACE OF MOTHER (State or country)
Plymouth Gern
14 THE ABOVE IS TRUE, TO THE BEST OF MY KNOWLEDGE
(Informant)
John D. Jeang Viathe
(Address) Jorkan St. Chiliford
16 July 10, 1911 Edward & Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
9
191 2
(Year)
I HEREBY CERTIFY that I attended deceased from July 9, 1911, to.
that I last saw the alive on fil 9
, 191.
7
and that death occurred, on the date stated above, at 57 m.
The CAUSE OF DEATH* was as follows :
quation intuition
(Duration)
.yrs.
mos.
ds.
Contributory. (SECONDARY)
(Duration) .
.... yrs.
mos.
ds.
(Signed)
laway Phi adamy
M.D.
July 10 1911 (Address) 295CucliaDo
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
In the
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death
.. yrs.
mos.
ds.
State ..
... yrs.
mos.
ds ..
Where was dlsease contracted, if not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
2 UNDERTAKER
ADDRESS
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
4.6 Cheluns ford
St. :
Ward)
(City of town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
PARENTS
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 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-
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