USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 28
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
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 bo ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State causo for which surgical operation was undertaken,
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 Commmmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH NoChelmsford & Buncette SK
St. :
Ward)
(City or town.) [lf 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
6 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
( Write the word)
tidon
16 DATE OF BIRTH
(Month)
(Day)
1
(Year)
If LESS than
1 day, ........ hrs.
.yrs.
.mos.
ds.
or ........ min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work.
athome
The CAUSE OF DEATH* was as follows :
nephritis
(Duration)
mos.
ds.
Contributory (SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
Joly 28
191./ ..... (Address).
North Chelingual
* 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 Attatucks
DATE OF BURIAL
July 29
.....
1911
......
ADDRESS
16 July 29 1911E dovand J Rotary Filed .. Af Varley. REGISTRAR -
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
/(Month)
27
(Day)
1911
(Year)
17
I HEREBY CERTIFY that I attended deceased from
July 12
191 / . to
27, 191.
that I last saw her alive on.
Jul 25 191.
1
and that death occurred, on the date stated above, at 5pm.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
leland
10 NAME OF
FATHER
mooney
11 BIRTHPLACE OF FATHER (State or country) feland
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
Wieland
14 THE ABOVEHIS TRILA TO THE BEST OF MY KNOWLEDGE
(Informan)
Michail lawn
0
(Address) 220 Thorndike
...
Julian Canon 2FULL NAME [If married or divorced woman or widow give maiden na;nc, also name of husband.1 @RESIDENCE 8 Bincette) nichelmsford
Julia Mooney Michael Camion
Registered No. 51
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
PARENTS
7 AGE To
not Known
......
... yrs.
M.D.
20 UNDERTAKER
C. A Malcon
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., 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 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 Mass (No.
St. : Ward)
(City or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford
Mass
Annie Roach . William R. Grover
Registered No.
52
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female
White
6 DATE OF BIRTH
I848
(Month) (Day)
(Year)
7 AGE
If LESS than
I day, ........ hrs.
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 Mass
10 NAME OF FATHER
William Roach
11 BIRTHPLACE OF FATHER (State or country)
Manchester
N. H ..
12 MAIDEN NAME OF MOTHER
Annie Ford
13 BIRTHPLACE OF MOTHER (State or country)
Manchester N.H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
William R.
Grover
(Address)
Chelmsford Mass
15 d July, 29, 1911 Edward . Rabbim
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
17
I HEREBY CERTIFY that I attended deceased from
1910, to.
.......
July 28".
......
19| 1 .......
that I last saw her alive on
Canla 28 4
1911.
and that death occurred, on the date stated above,
at 3 6.m
The CAUSE OF DEATH* was as follows :
Gastro-entérites
.
(Duration)
/
.. yrs.
mos.
ds.
Contributory (SECONDARY)
(Duration). .. yrs,
mos.
ds.
(Signed)
Amara toward
M.D.
July 29, 1911 (Address).
Chelmsford mare.
* 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
Edson
Cemetery
DATE OF BURIAL
July 34, 1911
20 UNDERTAKER
L.M. Young
ADDRESS
33 Prescott of
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
PARENTS
In the
28
1911.
(Month)
(Day)
(Year).
62 .yrs. 8 .mos. 3 .ds.
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
Married
52
Annie Grover
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, Sar- eoma, etc., of .. ...... (name origin: "Cancer " is less definite; avoid use of "Tumor" for malignant ncoplasms) ; Measles ; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: 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," "Hacmorrhage," " 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 septicemia," " 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.
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 Conumwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH North Chelmsford (No.
St. : Ward)
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
North
Chelmsford
Mass
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female
White
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH
(Month)
(Day)
-
(Year)
7 AGE
If LESS than I day,. hrs.
-
yrs.
6
mos.
ds.
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).
9 BIRTHPLACE (State or country)
Boston
Mass
10 NAME OF FATHER
Alfred Miller
11 BIRTHPLACE OF FATHER (State or country)
England
12 MAIDEN NAME OF MOTHER
Mabel Cramer
13 BIRTHPLACE OF MOTHER (State or country)
Boston Mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Alfred Miller
(Address)
North
Chelmsford Mass
15 Filedton Joly 31 , 1911 Edward & Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
30
(Month)
(Day)
191 /
(Year)
17
.
I HEREBY CERTIFY that) I attended deceased from
23 1911 10 July 30
...
1911
that I last saw h /2 alive on
191./.
and that death occurred, on the date stated above, at 530in
The CAUSE OF DEATH* was as follows :
(Duration)
yrs.
mos. ...
ds.
Contributory (SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
JE Vaney
M.D.
fach Se, 19V (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
DATE OF BURIAL
Riverside Cemetery aug1, 1911
20 UNDERTAKER
ADDRESS
6. m. Young 33 Prescott of
Sar-
les
s);
id-
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
53
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Arvila
Miller
Registered No.
53
1
PARENTS
7
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 engincer, Stationary fireman, etc. But in many cases, cspecially 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 tbe 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 Nonc.
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 (tbe only definite synonym is " Epidemic cerebro-spinal meningitis") ; Diphthcria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia") ; Lobar pneumonia, Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
1
1
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," "Collapsc," "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
PLACE, OF DEATH Celebreford (No Gorhan
2 FULL NAME Bernice/ Ragers
[If marricd or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Savi Chelmsford +
PERSONAL AND STATISTICAL PARTICULARS
3 SEX COLOR OR RACE female White
6 DATE OF BIRTH
(Month)
(Day)
30
1910
(Year)
7 AGE
If LESS than
I day, ....... hrs.
yrs.
8
mos.
ds.
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) Rayburn Mass
10 NAME OF
FATHER
James Ragen
PARENTS
11 BIRTHPLACE OF/FATHER State or country select
12 MAIDEN NAME OF MOTHER Lina Marlon
18 BIRTHPLACE OF MOTHER (State or country)
Lawell
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Gina Ragers.
(Address)
Lee Ist Lawelt
15
Filed .. 191
.....
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
7, 1911 .... that I last saw his alive on 3, 1911 and that death occurred, on the date stated above, at 10 pm
The CAUSE OF DEATH* was as follows :
Castro Encanta
(Duration)
yrs.
mos.
ds.
Contributory .. (SECONDARY)
(Duration) yrs.
mos. ds.
(Signed) A. By Jaha M.D.
(Address) 53 Cordial
.....
* 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
Casas Cerepron
DATE OF BURIAL
Chy 4
19/11
UNDERTAKER
ADDRESS
Les
as) :
d.
1
Sur-
important. See instructions on back of certificate.
54
(City or town.)
[If death occurred in a hospital or institution, give its NAME. instead of street and number.]
Registered No.
54
MEDICAL CERTIFICATE OF DEATH
(Month) 7 19111.
7 (Day) (C (Year) -
16 DATE OF DEATH
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
St. : Ward)
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
or
...... min. ?
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 1 and cvery 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-
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.