USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 4
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DATE OF BURIAL
May 16,90
UNDERTAKER I. H Dermott
ADDRESS Jo yerhand
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from .. a/n. 26 1960 to May 13 1980, 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 :
Primary :
Herpes Zoster
(Herpes Zoster)
.. (DURATION) 17
DAYS
Contributory :
Senile
(DURATION) . .. DAYS
(Signed).
Amara toward
M.D.
Thay 14 1960 (Address).
Chilinstord Mart.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
years ..
months. days
Where was disease contracted, if not at place of death ?
Filed May 16, 1960 Edward S. Rolling
Clerk
Vous
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME instead of street and number.
t In case of married or divorced woman, or widow. # State or country ; also city, town or county, If known,
§ Name and address of person giving statisticai detalls. Il Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
Death * S
-
THE COMMONWEALTH OF MASSACHUSETTS
201
Chelmsford
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Sarah M C Holt.
Registered No#3]
42
Place of
Death * S
North chelmsford Mass.
Date of l
Death
May 18th 1999
Residence
North Chelmsford
Age.
80
.years ...
............ months ..
.days
STATISTICAL DETAILS
SEX
Female
COLOR
White
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Married
MAIDEN NAME +
Sarah M C Ferson
HUSBAND'S NAMEt George B Holt
BIRTHPLACE #
AMtrim N H
NAME OF
FATHER
Bardford Ferson
BIRTHPLACE
OF FATHER#
Antrim N H
MAIDEN NAME
OF MOTHER
-
Sally Colby
BIRTHPLACE
OF MOTHER #
Bennington
N H.
OCCUPATION At Home
INFORMANT §
Husband
PHYSICIAN'S CERTIFICATE
! HEREBY CERTIFY that I attended deceased during last illness, from May 14 . 1910 to May 18 19/0, 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 :
Primary :
Hemiplegia
. (DURATION) KL
.DAYS
Contributory :
(DURATION). .. DAY8
(Signed)
FE Varney
M.D.
May 20 19/0 (Address).
I chelcuffed
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
.. years.
. months. days
Where was disease contracted,
If not at place of death ?.
Filed May 21 1910 Edward & Robbin
Town
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give its NAME Instead of street and number.
t In case of married or divorced woman, or widow. # State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVAL !! North Chelmsford
DATE OF BURIAL
May 21th 191910
UNDERTAKER
ADDRESS
39 Prescott Name of cemetery,
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Leroy A. Cheney
Registered No. 43I 43
Place of
Death * S
Chelmsford Klass
Date of l. Death May 2I, TOTO ...
19
Residence
Chelmsford Mass
. Age ..
22
.. years ..
.months.
.days
STATISTICAL DETAILS
SEX
Male
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Single
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
Lowell Mass
NAME OF FATHER
Wilbur A. Cheney
BIRTHPLACE OF FATHER#
Claremont N.H.
MAIDEN NAME OF MOTHER
Florence E. Rice
BIRTHPLACE
OF MOTHER #
Highgate Vermont
OCCUPATION
Clerk
INFORMANT §
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Mayoy . 19/ to May 21 1910, 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 :
Primary : Endocarditis
Embolism Brain (OURATIO
2 Weeks.
Contributory :
..
.... (DURATION). .. DAY8
(Signed)
Antun 4, Scoloria
-
M.D.
May 2010 (Address).
Chelmsford, Mass.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Place of Death ? . years.
months. days
Where was disease contracted,
if not at place of death ?
Filed may 23
19/6
Edward S. Rolling
Cierk
Father
PLACE OF BURIAL OR REMOVAL II ForeFathers Cemetery Chelmsford Mass
DATE OF BURIAL
Lay 23. IO.IO
UNDERTAKER l.M.
ADDRESS
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If in a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow.
# State or country; also city, town or county, If known.
§ Name and address of person giving statistical detalls.
0
33 Prescott Il Name of cemetery.
ALL NAMES TO BE IN FULL
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD -
202
Chelmsford
7
:
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
STATISTICAL DETAILS
SEX
male
COLOR
white
SINGLE, MARRIED, WIDOWED, OR DIVORCED Married
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE #
northfield w/-
NAME OF
FATHER
unknown
BIRTHPLACE
OF FATHER#
unknown
MAIDEN NAME
OF MOTHER
unknown
BIRTHPLACE
OF MOTHER #
unknown
OCCUPATION Laborer
INFORMANT § Wider- .
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
Tachira M2 May 24.19/0
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that i attended deceased during last
illness, from.
.19
to. .. 19 , 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 : Suicide
Primary :
Death by drowning
. (DURATION) .. DAYS
Contributory :
.(DURATION).
.. DAY8
(Signed) ...
Robert - C. Bull
M.D.
mary
...
.. 19/0 (Address).
Laurel
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
. years.
. months.
days
Where was disease contracted,
If not at place of death ?
f
Filed May 24 1910 Oderand . Rothing.
Vanni
1
Clerk
* City or town, street and number, if any, If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If in a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. # State or country; also city, town or county, If known.
§ Name and address of person giving statistical detalls.
UNDERTAKER ADDRESS p.m. Young 33 Prescott & M Name of cemetery.
(CITY OR TOWN.)
FULL NAME Clarence
Dinsmoor
Registered No ..
# 31 44
Place of )
Death * S
merrimack
River
Death
Date of l
may 14
..... 19/0
Y
Residence
54 Gillis Street Washua n. H. Age.
38
... years ..
.months .. .. days
THE COMMONWEALTH OF MASSACHUSETTS
203
RETURN OF A DEATH
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from Mar, 17 1960 to May 20 1960, 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 :
Primary :
Cerebral embolism
.(DURATION) ..
3
DAYS
Contributory :
Trama poisoning
4
Some months
... (DURATION).
.. DAYS
(Signed) ..
amara toward M. D.
May 2/ 1994 (Address).
Chelmsford Mano.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
years ..
months.
days
Where was disease contracted,
If not at place of death ?
INFORMANT §
Mrs. W. S. Parker
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
May 23
1900
UNDERTAKER
Waller Puchary
ADDRESS
204 Chelunsford
(CITY OR TOWN.) 45
FULL NAME.
Willard Sullivan Parker
Registered No ..
Place of Chekuofond Mars.
Date of May
my 20
19/
Death
-
6
.years.
.months.
.. days
STATISTICAL DETAILS
SEX
m
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE #
Chelineford.
NAME OF
FATHER
Willard Parker
Parker
BIRTHPLACE
OF FATHER#
MAIDEN NAME
OF MOTHER
Phache Mitchell
hoe
BIRTHPLACE
OF MOTHER #
Come patiño, n. H.
OCCUPATION
farmer
Filed May, 23 1960 Edward Robbing
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, glve facts called for under "Speclal Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. # State or country ; also city, town or county, If known.
§ Name and address of person glving statistical details. || Name of cemetery.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
Death *
...
Residence
Age.
51
1
٢
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Place of l
Death *
$
Chelmsford Gentert
Date of l
Death 1 May 24 1910
Residence
Age 21
.. years ..
.. months.
.. days
STATISTICAL DETAILS
SEX Le
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
Prefelle Tartin
HUSBAND'S NAME Ť Charles & Hennes
BIRTHPLACE# Granada
NAME OF FATHER
BIRTHPLACE OF FATHER# Barradu.
MAIDEN NAME OF MOTHER Lessu Lafleur
BIRTHPLACE OF MOTHER # Canalla
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
UNDERTAKER
ADDRESS 738
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last .. 19 illness, from May 7 19/ to. , 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 :
Primary :
Tuberculosis
of the
Boonello
not known exactly
.. (DURATION) ...
... DAY8
Contributory : OS Bollehumer
.(DURATION). .. DAYS
(Signed) ... A.
rumeur
M.D.
may 2419/0 (Address).
8/3 prawach.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Place of Death ? .. years ... . months. . days
Where was disease contracted, If not at place of death ?
Filed May 2.5 1910 Edwards. Robbing 0
Clerk
* City or town, street and number, If any, If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow. # State or country; also city, town or county, if known,
§ Name and address of person giving statistical detalls. Il Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
205
Grefelle L. Hemen/
Registered No .. 46
حبيب
COMMONWEALTH OF MASSACHUSETTS
206 Chelmsford
RETURN OF A DEATH
FULL NAME
Samuel Lane Dutton
........ Registered No.
Piace of 1
Chelmsford, Dass.
Date of )
May 24
1980
Death S .........
18
.. months. 12 ... days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME t HUSBAND'S NAME t
BIRTHPLACE #
acton mars.
NAME OF
FATHER
Solomons. Dulta
BIRTHPLACE OF FATHER# Bedford, Mace
MAIDEN NAME OF MOTHER Charlotte O. Hitching
BIRTHPLACE OF MOTHER # Carlisle, mars.
OCCUPATION
TON Retired Physician
INFORMANT § Edward Detten(2)
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL Arefactura Com. Shehates May 30. 1990
ADDRESS
UNDERTAKER
Wallen Berham Schusterd.
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from .. 1980 to May 27 1900, 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 : Primary : Senile
(DURATION) ..
... DAYS
Contributory :
Malarial pouronong
during civil war (DURATION). DAYS
/
(Signed).
Amara Itoward M.D.
May 28 199 G. (Address).
chelmsford man
SPECIAL INFORMATION only for Hospitais, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
. years ..
months days
Where was disease contracted, If not at place of death ?
Filed
May 30
*1960
Edward S Roffin
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." if in a Hospital or institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow.
# State or country , also city, town or county, if known.
§ Name and address of person giving statistical details. || Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
Death * S
Residence
Age
75-
... years.
(CITY OW TOWN.) 47
مجه
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate. N. B .- Every ftem 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
2.07
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)
Single
Femalo
White
6 DATE OF BIRTH
Nov.
29
I902
(Month)
(Day)
(Year)
7 AGE
If LESS than I day, ....... hrs.
yrs.
C)
mos. .
I
ds.
or ........ min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work
School Girl
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE (State or country)
Chelmsford Mass
10 NAME OF FATHER
HenryO. Miner
PARENTS
11 BIRTHPLACE OF FATHER (State or country) - Lowell Mass
12 MAIDEN NAME OF MOTHER
Elizabeth McToarue
13 BIRTHPLACE
OF MOTHER
(State or country)
Scotland
14 THE ABOVE IS TRUE/TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Worth Chilisford
15 Filed Jeme 1. 190 Edward I. Salt Pove
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
May
30
(Month)
(Day)
1910
(Year)
17 I HEREBY CERTIFY that I attended deceased from
191
may 30
0
that | last saw h ... alive on. . 1910 and that death occurred, on the date stated above, at 5300 m. The CAUSE OF DEATH* was as follows :
meningitis
8 or 10 hours
(Duration)
.mos. ds.
Contributory.
SECONDARY er mai (Duration).
7 E Varney
(Signed)
May 31
.....
191 ....... (Address)
Hi Chelista M.D.
* 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 BURIALTOR REMOVAbra St.Joseph's Cemetery
DATE OF BURIAL
June I 1910
North Chelmsford
(No Mt. Pleasant St St. :
Ward)
Elizabeth Miner
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Mt. Pleasant St. North Chelmsford
Registered No.
48
to
yrs. .... . mos. ds.
ADDRESS
20 UNDERTAKER
. OKimwell nes 324 May Hogy
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) Automobilefactory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," "Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc .- Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Ilousewife, 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 neoplasms) ; Measles ; Whooping cough; Chronie valvular heart disease; Chronie 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
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Madel R.Moore
Registered No. 13I
Place of )
North Chelmsford
Mass
Date of Į
Death June .... 2.19IQ ........ 9
Residence
North Chelmsford
Age
3
.years .. 6 months .. .I2.
...... days
STATISTICAL DETAILS
SEX
Female
COLOR
White
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
Chelmsford Mass
NAME OF
FATHER
Robert
Moore
BIRTHPLACE
OF FATHER#
Ireland
MAIDEN NAME
OF MOTHER
Mary Smith
BIRTHPLACE
OF MOTHER #
Ireland
OCCUPATION
None
INFORMANT §
FatBE r
PLACE OF BURIAL OR REMOVAL il
DATE OF BURIAL June 4. 1960
River Side Cemetery
UNDERTAKER
b. m. trung
ADDRESS
33 Prescott of
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. May 20 19/0 to pone 2 19/0, 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 : Primary :
. (DURATION) 14
... DAYS
Contributory :
.(DURATION) ... DAY8
Signed)
JE Vaney
M.D.
.19/0 (Address) ..
H- Chelles.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Piace of Death ? years. days months.
Where was disease contracted, If not at place of death ?.
Filed
June 4 1910 Oderand, Rafting
Vom Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow.
# State or country ; aiso city, town or county, if known.
§ Name and address of person giving statistical detalis. [] Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
208
Chelmsford
Death * S
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 West Chelmyard Masa
St. ; Ward)
2 FULL NAME
Emma
A Spalding
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
West Chelowland Mark !
Widow Einmal A Longley tu, and. Francis
Registered No. 50 $
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Firmala.
4 COLOR OR RACE
white
5 SINGLE
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
widow
6 DATE OF BIRTH
(Month)
19
(Day)
1848
17
(Year)
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
murisvan
(b) General nature of industry,
business, or establishment in
which employed (or employer).
Housewife
9 BIRTHPLACE
(State or country)
West Chelmylord. mars
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
milbury Mass
12 MAIDEN NAME
OF MOTHER
Eliza Simmons
13 BIRTHPLACE
OF MOTHER
(State or country)
R.9.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. Mabel. Chaholding
(Address) aufindale Mans &
Filed June 10, 1910 Edward & Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
June
1910
(Month)
(Day)
( Year)
in tal keet nee
I HEREBY CERTIFY that I attended deceased from
March ,
, 1916
June 9'
, 1910
to.
If LESS than
I day,.
hrs.
that I last saw her alive on
., 19k
and that death occurred, on the date stated above, at/030 pm.
The CAUSE OF DEATH* was as follows :
ataxia
Have ablend her mener leaster
this disease for abril. 14 years,
yrs.
.mos.
. ..
ds.
Contributory. (SECONDARY)
.. (Duration)
yrs. . .
mos.
ds
(Signed)
JE Varney
M.D.
funela
.....
. 191 º (Address)
* If death followed Injury or violence the certificate of death must be made out by the Medleal 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
DATE OF BURIAL
West Chelombard Han June 12 1910
20 UNDERTAKER
David L. Freis
ADDRESS
WEstead Man
. ,
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
209
....
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
7 AGE 61 yrs. 7 mos.
20
ds.
10 NAME OF
FATHER
Jonas Longdong
STANDARD CERTIFICATE OF DEATH.
1
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- mun, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE 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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