USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 10
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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; Broneho- 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; 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 septicaenia," " 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
important. See instructions on back of certificate.
22 The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH East Chelmsford
(No.
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
. John Bowden.
[If married or divorced woman or widow
give maiden name, also name of
hushand J
@RESIDENCE
East
Chelmsford.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DRAThe 23
I912
191
(Month)
(Day)
(Year)
I HEREBY CERTIFY thatel attended deceased from
Apr. 24
,
1912 to
June 19
1912
...
that I last saw h /me alive on
Jun 19
191
-
.... .
and that death occurred, on the date stated above, at ....
12
.m.
The CAUSE OF DEATH* was as follows ;
vielen of theart
.(Duration)
chronic Maplerit
ds.
Contributory
y ..
(SECONDARY)
... (Duration)
..... yrs.
mos.
ds.
(Signed)
W. A. Whuman
M.D.
6-24. 19/2 (Address).
frwill
* 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 plece
of death
yrs.
mos.
ds.
Stete.
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 Edson Cem Lowell
June
2.6.1912
...
191
20 UNDERTAKER
Weinbeck 16 Market
DATE OF BURIAL
15 Filed Jr 0
June 26 , 1912 Edward S- Robbins
- REGISTRAR
& SINGLE,
MARRIED
WIDOWED,
OR DIETried
6 DATE OF BIRTH
Feb 22 1840 (Write the word)
(Month) (Day)
-
(Year)
7 AGE
If LESS than I day, hrs.
72
yrs
11 mos.2
ds.
........ min. ?
8 OCCUPATION (a) Trede, profession, orLumber particular kind of work
Mer.
(b) General nature of industry, business, or esteblishment in which employed (or employer) ..
9 BIRTHPLACE (State or country) England
10 NAME OF FATHER James Bowden
PARENTS
II BIRTHPLACE OF FATHER (State or country) England
12 MAIDEN NAME OF MOTHER Catherine Trombly
13 BIRTHPLACE OF MOTHER ENLAND (State or country)
England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE J H Bowden (Informent) .Chelmsford (Address)
(City or town.)
E
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
3 SEX
4 COLOR OR RACE
Male White : 3
ADDRESS St Lowell
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 Ilousc- 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 porsons 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 dėfinite 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-
eulosis of lungs, meninges, peritondeum, 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 ; 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 discase can be ascertained as the cause. 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 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
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
(No.
......
Bostonas Road
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
ªFULL NAME Céliza June Emerson
[If married or divorced woman or widow Parkleurat H. H. Emerson give maiden name, also name of husband.] @RESIDENCE Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widow
6 DATE OF BIRTH +3abril 5 1839 (Month) (Day) (Year)
17 I HEREBY CERTIFY that X)attended deceased from
, 1912 to
1912
that I last saw her alive on.
June 29
19| 2
and that death occurred, on the dato stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Acute Indigestion-
(Duration)
yrs.
mos.
了应
ds.
Contributory
(SECONDARY)
mos.
ds.
(Signed)
Aicher I. Scolina
M.D.
Luce 30, 1912 (Addres).
* 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
......
In the
.yrs.
.mos.
ds
Where was disease contracted, If not at place of death ?.
Former or usual residence.
M
19 PLACE OF BURIAL OR REMOVAL Forefathers Com.
DATE OF BURIAL
July 2- 1912
(Address)
Chelmsford
16
Filed ..
July 2, 1912 Edward J. Robbery
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
- June
29
(Month)
(Day)
191 2
(Year)
If LESS than
1 day, ........ hrs.
7 AGE
73
2
yrs.
mos.
24
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)
Chelmetal
10 NAME OF
FATHER
Hezekiah Rarelunet
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Chelucford
12 MAIDEN NAME
OF MOTHER
Julia A Butterfield
13 BIRTHPLACE
OF MOTHER
(State or country)
Chelmsford
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mro Sargent (Daughter)
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
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
1,28 Chelmsford
Registered No.
42
20 UNDERTAKER
Natur Perhour
ADDRESS
Chelmsford.
.yrs.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that tho relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of agc. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, 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 necdcd. As cxamples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the sccond 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 usc of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
eulosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- eoma, ctc., 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 dcath), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " All- 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 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 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
PLACE OF DEATH
STANDARD CERTIFICATE OF DEATH Chelmsford (No
St. : "
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
"FULL NAME Anna M Paasche!
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Neilson.
Alexander. Pa asche.
Chelmsford.
Registered No.
1/3
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
4
(Month)
(Day)
1912.
(Year)
6 DATE OF BIRTH
June IO
I823
1
(Month)
(Day)
(Year)
7 AGE
89
yrs.
0
mos.
24
... ds.
or ........ min. ?
8 OCCUPATION-
(a)' Trade, profession, or
particular kind of work
At Home.
The CAUSE OF DEATH* was as follows : Lectureal Degeneration
Senility
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country) Norway .
(Duration).
.. yrs.
mos.
ds.
10 NAME OF
FATHER
Neils Neilson.
Contributory
(SECONDARY)
(Duration)
Anhus G. Scolo
.yrs
mos.
ds.
(Signed)
1912 (Address)
Chelinsford, man
* 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 Edson Cem Lowell July 7
DATE OF BURIAL
1912
191
ADDRESS
16 Filed ... July 7, 1912 Edward J. Rotting
REGISTRAR J
20 UNDERTAKER
A Weinbeck
16 Market St Lowell
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
PARENTS
12 MAIDEN NAME OF MOTHER Rumslerve.
13 BIRTHPLACE
OF MOTHER
(State or country)
Norway.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(InformarAlfred Paasche. (Address)
Cheimnsford
129
(City or town.)
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED Widow.
(Write the word)
17 I HEREBY CERTIFY that Attended deceased from
191
.... ,
, to
July 3, 1912.
that I last saw her alive on
. 19/2/
and that death occurred, on the date stated above, at. m.
-
M.D.
Il BIRTHPLACE OF FATHER (State or country) Norway.
If LESS than
1 day ......... hrs.
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 linc is provided for the latter statement ; it should be used only when needed. As examples: (() 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- kcepers 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 domostic 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-
eulosis of lungs, meninges, peritoneum, etc., C'arcinoma, Sar- coma, 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 discases 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 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 Truccion Sheet N
2 FULL NAME. [If married or divorced woman or widow give maiden name, also name of husband. 1 @RESIDENCE
16
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED
WIDOWED,
--
OR DIVORCED
(Write the wordy WOUs
6 DATE OF BIRTH
(Month)
(Day)
I
(Year)
7 AGE
2
.............. yrs.
mos.
2
ds.
or ......... min. ?
If LESS than I day, ........ hrs.
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)
10 NAME OF
FATHER
tausteakry
PARENTS
11 BIRTHPLACE OF FATHER (State or countye) pat Chelms lad
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)*
WistAnd Mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE .
(Informant)
Lamis I Lechey Lathey
(Address)
heath tebedadad
16 Filed July 12 1912 Edward A. Rolling
......... REGISTRAR
Diabetes Mellitus
.. (Duration) .
Q .. mos.
............. yrs. ....
.ds.
Contributory (SECONDARY)
.(Duration) .
............... yrs.
.......
.mos. ds.
(Signed)
July 11, 19/2
(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). ⑈
In the
At place
of death
.. yrs
. ..........
. mos.
... ds.
State ...
......... yrs.
ds. ..... Where was disease contracted,
If not at place of death ?.
Former or usual residence. .......
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL July 1/1912
ADDRESS
20 UNDERTAKER
1130 Fort Cheluiford
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
7
10
(Month)
(Day)
191.2
(Year)
17
I HEREBY CERTIFY that I attended deceased from
June 25, 1912, to
Jul
1. 1912
that T last saw h ... alive on.
., 1912 and that death occurred, on the date stated above, at 1.30 Pm. The CAUSE OF DEATH* was as follows :
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
.
ford
M.D.
.mos.
J
44
St.
Ward)
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthifulness 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 tho 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.
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