USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 11
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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 | Part 38 | Part 39
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, 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.
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, Inth Chelwex ford (No Juneton It unceton
St. ;....
.Ward)
Michael Harrington
Registered No. 45
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
14 COLOR OR RACE
Verual White
6 DATE OF BIRTH
(Month)
(Day)
If LESS than [ day, ........ hrs.
... yrs.
.. mos.
ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
at Am
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
at Home
9 BIRTHPLACE
(State or country)
Queland
Contributory ...
Chunis Bronchitis
....
(SECONDARY)
.(Duration) .............. yrs. ....
2
mos.
ds.
(Signed)
M.D.
Salve, 19/2(Adres
Chefmulario
* 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 placo
of death.
.. yrs.
In the
mos ..
ds.
State.
... yrs.
.mos.
ds
Where was disease contracted, If not at place of death ?.
Former or usual residence. .....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
July 17
...
1912
(Informant) ..... >
(Address) uscita Vt. With Chelangford
16
Filed.
July 12, 1912. Edwards, Rolling
REGISTRAR
16 DATE OF DEATH
7
10
2
191.
.......
(Month)
(Day)
(Year)
1832 17 (Year) I HEREBY CERTIFY that I attended deceased from May 1, 19/2, to July 10, 1919
that I last saw her alive on 29, 199 and that death occurred, on the date stated above, at 6 am. The CAUSE OF DEATH* was as follows :
Semila Debilità
... (Duration)
.............. yrs.
.... mos. .........
.. ds.
10 NAME OF
FATHER
Michael Sullivan
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Quifaut
12 MAIDEN NAME
OF MOTHER
Ollen dy nel
13 BIRTHPLACE
OF MOTHER
(State or country)
Queland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Ellen Samente Naughty
Chelunsford 13/
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Man Harrington.
Man Villuda
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Princeton It worth Cheliveard
6 SINGLE,
· MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
7 AGE 80
...
0
20 UNDERTAKES
ADDRESS det Dowell Un 32& Manget Of.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relativo healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager,"" Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Houscwork, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, 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 necd 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," "Uraomia," " 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.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
8 SEX Female 7 AGE PARENTS 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 Thatchersfond (No) May Shell)
St. ;.
.............. Ward)
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
....
Sheel Dora Chiha Ind Registered No.
46
PERSONAL AND STATISTICAL PARTICULARS
4
6 DATE OF BIRTH
....
(Month)
(Day)
.....
(Year)
$ 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
Lohn 2 Keuch.
11 BIRTHPLACE .- OF FATHER (State or country) wines Eduard Seland
12 MAIDEN NAME OF MOTHER
(margaretof the manual
13 BIRTHPLACE OF MOTHER 20 ftchiliAnd
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) (, (Address) May Sheet hatschile Ind
15 Filed July 12/1912 Edward Do Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
7
1$
1919
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
July 11, 191, to.
July 11
.....
191.2
that I last saw h alive on.
July 11, 192,
and that death occurred, on the date stated above, at 3Pm.
The CAUSE OF DEATH* was as follows :
atelectasia
.
.(Duration)
.yrs.
.mos.
€
Contributory. (SECONDARY)
5
(Duration) ...... yrs. mos. ds.
(Signed)
........ M.D.
..... ily .....
191.A.
(Address) ..
elmsford,
* 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
191.9
20 UNDERTAKER
ADORESS
1137 Chiliusing (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
4 COLOR OR RACE
6 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1
If LESS than Day.hrs.
................ Y.s. mos. ds.
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 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 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 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.
:
The Commonwealth of Massarlutsetts
STANDARD CERTIFICATE OF DEATH
' PLACE OF DEATH,
Chelmsford
(No.
Rechuden Road
St. :
Ward)
[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
Rechadra Road
Registered No. 117
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
₦
C
(Month)
(Day)
15.92
(Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
-
The CAUSE OF DEATH* was as follows :
Fil stucke.
(Duration)
yrs.
mos. ds.
Contributory ... (SECONDARY)
.(Duration) ... yrs.
mos. ds.
(Signed)
July 15
1912 (Address).
160 Rommackdo.
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
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.
.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
William Mcclure
(Address) Richardern Rd. N. Chelmsford, No. Chelmsford
16 File July 16, 1912 Edwards Robbins - REGISTRAR
19 PLACESOF BURIAL OR REMOVAL
DATE OF BURIAL July 17, 1912
20 UNDERTAKER
J. G. Weinbeck
ADDRESS
1% Marketst
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX male 7 AGE PARENTS 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 ....
4 COLOR OR RACE
white
5 SINGLE
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
single
6 DATE OF BIRTH
May
14
1882 17
(Month)
(Day)
(Year)
If LESS than I day, ........ hrs.
30
.... yrs. / .mos. ds.
or ........ min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work farmer
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE (State or country) north Chelmsford
10 NAME OF
FATHER
William
11 BIRTHPLACE OF FATHER (State or country) Ireland
12 MAIDEN NAME OF MOTHER Josephine (?)
13 BIRTHPLACE OF MOTHER (State or country)
Ireland
MARGIN RESERVED FOR BINDING
Frage H. The Clare
133 Chelmsford (City or town.)
M.D.
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 evory 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, 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 iu 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 tho occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasmns) ; 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 " (mcrely 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. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident ; Revolver wound of head - homicide ; Poisoned by carbolie acid - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."
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.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH West Chelmsford (No.
2 FULL NAME vaci
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
5 SINGLE
MARRIED,
WIDOWED
Widow
OR DIVORCED
(Wirkte the word)
16 DATE OF DEATH
July
17
1912
(Month y
(Day)
(Year)
6 DATE OF BIRTH
april
13
(Month)
(Day)
(Year)
7 AGE
82
.yrs.
mos.
ds.
I day, ..
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)
Canada
10 NAME OF
FATHER
Not Kincom
PARENTS
II BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) :
My Ja Peck
(Address)
What thecloneford
15
Filed 191
REGISTRAR
....
.mos.
ds.
(Signed)
July 18, 1912 (Adres).
Unnanchang
* 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.
In the
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: W Chetomford
DATE OF BURIAL
20 UNDERTAKER!
ADDRESS
Johna ciembecky Market
-
134
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No. 1/8
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
Hence 21, 1912 to.
4 17, 192
If LESS than
that I
that I last saw her alive on.
.,
191.2,
and that death occurred, on the date stated above, at.
.m.
The CAUSE OF DEATH* was as follows :
(Duration)
......... yrs.
.mos.
ds.
Contributory ..
(SECONDARY)
- ((Duration)
.... yrs.
Lage
A
M.D.
Ward)
St. :
Leduc
Joe Rafanette David Reduc
3 SEX
tef max White
4 COLOR OR RACE
1830
17
MARGIN RESERVED FOR BINDING
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, o. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fircman, 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 laborcr, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Hlousc- 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 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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