USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 9
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4. Deaths under circumstances unknown, as A person found dead, etc.
THE COMMONWEALTH OF MASSACHUSETTS
227
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Ellen Softin arbeitund
Registered, No ....
68
Place of 1
west bloemhard
Death * S
Residence
West Chelmetne
Age
.. years ...
.. months.
21 days
STATISTICAL DETAILS
SEX
Female Muito
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME t
HUSBAND'S NAME +
BIRTHPLACE # West blehurford
NAME OF FATHER Carl Osterland
BIRTHPLACE OF FATHER# Sweden
MAIDEN NAME OF MOTHER Tallenis Peterin.
BIRTHPLACE
OF MOTHER #
Sweden
OCCUPATION 200ml
INFORMANT § Carl Osterland
PLACE OF BURIAL OR, REMOVAL !!
DATE OF BURIAL
UNDERTAKER ADDRESS AA Werwhich Samell
Tha22
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended, deceased during last illness, from. Sikl. 3 .19/0 to 11-10 ....... 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 : dual
Primary :
mamie
Que brith
.(DURATION). DAYS
Contributory :
... (DURATION) .. .. DAY 8
(Signed)
JE Varney
M.D.
Soft-10 1910 (Address).
n. Chilide
SPECIAL INFORMATION only for Hospitals, Institutions, Translents, or Recent Residents.
How long at Place of Death 7 years ..
months. days
Where was disease contracted, If not at place of death ?
Filed Self.10
19/0
Camandro Polling
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 detalis. Il Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
Date of l
Sieht 10 1910
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
Chelmsford
(No
St. :
Ward)
Registered No.
69
3 SEX
4 COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
DATE
March
22
(Month)
(Day)
18+617
(Year)
7 AGE
64
If LESS than 1 day, ....... hrs.
.yrs.
or
...... min. ?
8 OCCUPATION
(a) Trade, profassion, or
particular kind of work
farmer
(b) Ganaral nature of industry, businass, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Canada
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Canada
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
Canada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Ins. Paul Smith
(Address)
16 any 24, 1910 Edward J. Rothing Filad
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
aug
.........
(Month)
22
(Day)
19 ! 0
(Year)
I HEREBY CERTIFY that I attended deceased from
191.
., to
, 1910,
, 191 6,
that I last saw h
alive on
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
-
Left Stausplease.
.yrs.
about 2 Man ( Ducation)
Contributory.
(Duration)
yrs.
mos.
ds.
(Signed)
Autres 4, Scabina
..... , M.D.
flug. 24.
.. , 1910 - (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 tha
of daath
yrs.
mos.
ds.
State. . ..
yrs.
mos.
ds.
Where was disease contracted, if not at place of death ?
Former or usual residence.
10 PLACE OF BURIAL OR REMOVAL Houfactura
DATE OF BURIAL
aug 24+
1910
Chelmsford. "Maso Cheli fino maso
20 UNDERTAKER
ADDRESS Waller Pechan Chelmsford.
228 Chequeford. (City of town.) [If daath occurrad in a hospital or institution, giva its NAME instaad of streat and number.]
2 FULL NAME
Paul Smith
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford. Mass
PERSONAL AND STATISTICAL PARTICULARS
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
mos.
ds.
10 NAME OF
FATHER
Carlis Smith
5
mos.
0.
ds.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary 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- kcepcrs 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 ('AUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fcver (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite; avoid use of " Tumor " for malignant neoplasms) ; Measles; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the strect, 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
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford Garten Class
St. :
Ward)
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE # Chefmadord Center Class
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
14 COLOR OR RACE
While
5 SINGLE
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
Suisole
៛ DATE OF BIRTH
March 14 th
(Month)
(Day)
19/1/ 17
(Year)
7 AGE
yrs.
3
ds.
or ....... min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work
0
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Thelineford Center
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Canada
12 MAIDEN NAME OF MOTHER (linas Martin)
13 BIRTHPLACE OF MOTHER (State or country)
Canada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
faces "tremblay
(Address)
Chelmsford tecuter
15 Filed.
Sept. 17, 1910 Edward ). Robbing
REGISTRAR
...
If LESS than
I day, ..
hrs.
that i last saw h ....... ...
alive on
, 191
and that death occurred, on the date stated above, at ...
m.
The CAUSE OF DEATH* was as follows :
(Duration)
yrs.
12
ds.
Contributory .. (SECONDARY)
mos.
ds.
(Signed) AuchinGe Scobuna
yrs. ..
M.D.
Sept. 17, 1910 (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 It forph
DATE OF BURIAL
Sept 18
191()
ADDRESS
229
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
10
16 DATE OF DEATH
Sept 17
(Month)
(Day)
19:0-
(Year)
I HEREBY CERTIFY that I attended deceased from
., 191.0, to ..
Aug 12 90-
MARGIN RESERVED FOR BINDING
2 FULL NAME
7
20 UNDERTAKER
taxe Jahr Cettert
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 lino 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 tho 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 reccive a definite salary), may be entered as Ilousewife, Hlouscwork, 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. - Namo, first, tho 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," unqualificd, 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) ; 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 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," ctc. 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.
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 Massariutsetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Noun Haus (No Chelenford Cents
:
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Edward &fox
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Registered No.
2/1
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE MARRIED WIDOWED, OR DIVORCED (Write the word)
Widowed
6 DATE OF BIRTH
(Month)
(Day)
1 (Year)
7 AGE
If LESS than I day, ....... hrs.
.. ... yrs.
mos.
ds.
Or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work
formaly
(b) General nature of industry, business, or establishment in which employed (or employer).
14 lion
9 BIRTHPLACE (State or country) leland
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Leland,
12 MAIDEN NAME OF MOTHER
hot known
13 BIRTHPLACE OF MOTHER (State or country)
Inland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
1 ( Address) hou C
15
Filed. Sept. 19, 1919 Edward &. Nothing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sept. 17
(Month)
(Day)
19! O.
(Year)
17 I HEREBY CERTIFY that I attended deceased from
Sept. 1
, 1910 to
Sept. 16
, 1910 ;
that I last saw h alive on ... Sept. 16, . 1916. and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH* was as follows :
Senility
Myocarditis
.. (Duration)
yrs.
...
mos. ...
ds.
Contributory (SECONDARY)
(Duration) ... yrs.
mos.
ds.
(Signed) Anten G. Scolonia
M.D.
Left. 17. 1910 (Address).
* If death followed injury or violenee 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 placa
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 XFf Paturi Counter
DATE OF BURIAL
Jest. 19. 1910
ADDRESS
20 UNDERTAKER
230 Cheles ford Mas
(City/or town.)
MARGIN RESERVED FOR BINDING
Labour
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 Ilouse- kcepers who receive a definite salary), may be entered as Ilousewife, Ilouscwork, 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 110 occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to tinie 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, peritonacum, etc., Carcinoma, Sar- coma, etc., of (name origin: "Cancer " is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraenia," "Weakness," etc., when a definite discase 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 dcad, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No So. (Helms. Mass.
Derome 3. Sheloin erome
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
So. Chelms. hans
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
m
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
6 DATE OF BIRTH
(Month)
(Day)
(Year)/
7 AGE
If LESS than
1 day ..... hrs.
mos.
+
ds.
or ....... min. ?
& 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)
Lowell Mass
10 NAME OF FATHER
Thu
John G. Melin
-
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Hudson, MIN
12 MAIDEN NAME OF MOTHER Sarah thorey
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Olija Melis
(Address)
So. Chelms. mars.
16 Sept. 20 , 1910 Edward & Rafting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sent.
19
(Month)
(Dáy)
19101
(Year)
17
Dsc 4
908 to 11/21.18
...
1910.
that I last saw h malive on
Sept. 18,
190
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Altrio-Achicoria
metalilas
2 years or more
(Duration) 1
.yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration) .
.. yrs.
mos.
ds.
(Signed)
Acho G. Scotovia,
M.D.
Left 20
..... 1910 ~ (Address).
Chiles for 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).
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 Edson Century , Lawell, Mas.
DATE OF BURIAL
Sept. 21,1910
.
20 UNDERTAKER
H.G. Weinbach
ADDRESS
so Midex, EX.
23/ Lowell (City or town.)
St. : Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
7.2
301
I HEREBY CERTIFY that I attended deceased from
1.837
72 .yrs.
16
...
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, Loeo- 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) Salcs- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statemeut. 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 (rctired, 6 yrs.). For persons who have 110 occupation whatever, write None.
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Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to tiule 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, Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
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