USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 27
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culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Mcasles ; 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 mere symptoms or terminal conditions, such as " Asthenia," " An- acmia " (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 Examinors:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violonce, 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.
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
1 PLACE OF DEATH STANDARD CERTIFICATE OF DEATH Chelles ford Mas No. South Chelayan Good
St. :
Ward)
(City or town.) [lf death occurred in a hospital or institution, give its NAME instead of street and number.]
John C. Haley
2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelunsford Marco
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
suite
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Vingle
16 DATE OF BIRTH
-
15.75 (Year)
7 AGE
If LESS than
1 day, ......
hrs.
... yrs.
mos.
ds.
Or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Miliman
(b) General nature of industry, business, or establishment in which employed (or employer) ..
Retail Milkman
9 BIRTHPLACE
(State or country)
Cheles ford Mas
PARENTS
10 NAME OF
FATHER
Samuel Staley
11 BIRTHPLACE
OF FATHER
(State or country)
Wieland
12 MAIDEN NAME
OF MOTHER
Budget Sales
18 BIRTHPLACE
OF MOTHER
(State or country)
Wieland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Bating N. Hales Brother
(Informant)'
(Address) Chelive food Centy
16 July 12, 1911 Edward 1. 0Horas
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
10%
..
191.1
......
/ (Month)
(Day)
(Year)
17
I HEREBY CERTIFY that | attended deceased from
Jul 10
, 1911, to Jul 10
1911,
that I last saw him alive on.
Jus /10
,
1911.
and that death occurred, on the date stated above, at 2 P. m.
The CAUSE OF DEATH* was as follows :
Cardiac failure following
heat exhaustion
3 hours.
(Duration)
de.
Contributory .. (SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
Chinasa toward
..
M.D.
Ane 10, 19/ (Address).
Chilmotorh.
* 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
ds.
of death
.. yrs.
mos.
„ds.
State ..
mos.
yrs.
....
Where was disease contracted, if not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL It Patry, Cemetery
DATE OF BURIAL
July 1201
20 UNDERTAKER
ADDRESS
324 Market UF.
MARGIN RESERVED FOR BINDING
Filed.4. 0
(Month)
(Day)
47, chelidond
Registered No.
47
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, Houscwork, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
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, Chronie 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 causc. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," " 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 Examinors :
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.
-
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH Chelmsford . (No Billencão
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Registered No. 48
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX 7,
1
4 COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED driver
(Write the word)
6 DATE OF BIRTH
18.33 17
(Month)
(Day)
(Year)
7 AGE
78
yrs. mos. ds.
or ........ min. ?
8 OCCUPATION Retired
(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)
PARENTS
12 MAIDEN NAME OF MOTHER Many & Slust
13 BIRTHPLACE OF MOTHER (State or country)
Chelmsford.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Grand T. Dadmin
(Address) elceluistud masa
16 Filed July 12, 1911 Edward J. Robbins 0
REGISTRAR
.. (Duration) .yrs. mos. 5 ds.
Sexe arteriosclerosis -
Contributory
(SECONDARY)
(Duration) yrs.
mos. ds.
Aucun I. Scolonia
M.D.
July 11. .. , 191 ........ (Address).
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
In the
of death
yrs
mos.
ds.
State
yrs.
mos.
ds ..
Where was disease contracted, If not at place of death ?
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Foret allies Cem Vily 12, 1911
ADDRESS
20 UNDERTAKER Walter Teclear Chelaufend.
10
191 7
(Year)
(Month)
(Day)
9
I HEREBY CERTIFY that/ attended deceased from Andy 5,, 1911, to ........ ......
If LESS than | day ....... . hrs. that I last saw h. alive on Anes 9 , 191.) , and that death occurred, on the date stated above, at 3G. m. The CAUSE OF DEATH* was as follows : Impactul fracture of
10 NAME OF
FATHER
Seace Cook Laws
11 BIRTHPLACE OF FATHER (State or country) ofchelmsford. tene
Chelmsford. 4.8.
Elvir Planter Dickinson Dickinson
2 FULL NAME
[If married or divorced woman or widow give maiden namc, also name of husband.]. @RESIDENCE lehelie ferd.
price & Laws, Barney P Dickerson.
16 DATE OF DEATH
July
(Signed)
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 (6) 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 ou 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 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 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, 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 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 Chelmsford .(No actor
St. :
Ward)
(City or town)) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No. 419
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
-
6 DATE OF BIRTH
TH March
(Month)
16
(Day)
7 AGE
If LESS than I day ......... hrs.
449 yrs. 03 mos. 2%
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)
Jo. Benekek me
10 NAME OF FATHER John Horman
PARENTS
11 BIRTHPLACE OF FATHER (State or country) york De.
12 MAIDEN NAME
OF MOTHER
Javal Farnham
13 BIRTHPLACE OF MOTHER (State or country)
Wells , Que .
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .
Mv. las C Simplow
(Address)
Chelmsford, Mars
16 Filed .. July 16, 1911
Edward Y, Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July,
(Month)
13
(Day)
191/
(Year)
I HEREBY CERTIFY that I attended deceased from
that I last saw her alive on
pus 13
191/ ,
and that death occurred, on the date stated above, at ... 80 m.
The CAUSE OF DEATH* was as follows :
Chronic Myocarditis
(Duration)
yrs.
mos.
ds.
Contributory. (SECONDARY)
(Duration)
yrs.
mos.
„ds.
(Signed)
Casa Howard
¥
Jay15, 1911 (Address).
Chelmsford man.
* If dcath 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
dedige, Chelmsford, Mand Vely 16, 1911
ADDRESS
20 UNDERTAKER
Walter lechan flugfeed
4%
Polizistina
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE lehelmsfind-
Morman, "
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
5 SINGLE,
MARRIED,
WIDOWED/
OR DIVORCEDanced
(Writ the word)
1862
17
(Year)
nov.
19ID, to
Jul 13
1911.
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, peritonaeum, etc., Carcinoma, Sur- coma, etc., of. (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasins) ; 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.
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) try Selten A.M.
12 MAIDEN NAME OF MOTHER Margaret Coffee
13 BIRTHPLACE OF MOTHER (State or country)
Cheland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Michael & Uchen
Of the
(Address) Intel Celertid
16 Filed July 26, 100 Edward S. Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX mal
4 COLOR OR RACE
Photo
5 SINGLE
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH
June
(Month)
16
(Day)
1911
(Year)
7 AGE
If LESS than I day, ........ hrs.
yrs.
1
mos.
8
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).
17
I HEREBY CERTIFY that I attended deceased from
July 23, 19/1, to
25,1911.
that I last saw him alive on.
July 66, 1911
and that death occurred, on the dato stated above, at 14954m.
The CAUSE OF DEATH* was as follows :
.
cholera
(Duration)
yrs.
mos.
ds.
Contributory ... (SECONDARY)
(Duration) Jaunes J. Haber
... yrs.
mos.
ds.
M.D.
(Signed)
July 26 10/
(Address) ..
No Chelmsford
* If deathfollowed 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 ....
W PLACE OF BURIAL OF RENOVALIALILY
DATE OF BURIAL
Failin fact. July 26101/
20 UNDERTAKER
ADDRESS
Het. OD well Ind 32 4 Mayet Ut.
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 North Chelub ford (No. Middleay
St. :
Ward)
Trehard M. Shea
2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Middlesy St barth Chelword
Registered No.
30
PERSONAL AND STATISTICAL PARTICULARS
Cheles fog 5,0
...
(Gfty or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
16 DATE OF DEATH
July
35
-
(Month)
(Day)
-
(Year)
MARGIN RESERVED FOR BINDING
9 BIRTHPLACE
(State or country)
Cheluis ford Maso
10 NAME OF
FATHER
Michael & Shea
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. Tho 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 oxamples: (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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