USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 12
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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 fever (thio 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, peritondeum, etc., Carcinoma, Sar- coma, ctc., of ........ ..... .. (namo 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 nced not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapsc," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite diseaso can bo 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 tho 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
-
135 Chelmsford (led)
......
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Charge a. Ingham
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Princeton h. Chelmsford (Kuch ) Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH July 18
(Month)
(Day)
1912 (Year)
6 DATE OF BIRTH
June (Month)
(Day)
(Year)
7 AGE
If LESS than I day, ........ hrs.
19. ... yrs. ..... mos ..... 11. .ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Butcher
(b) General nature of industry, business, or establishment in which employed (or employer).
* * ×
(Duration)
.yrs.
.mos.
ds.
Contributory.
(SECONDARY)
(Duration) .yrs.
mos. ds.
(Signed)
I.V. Weign
M.D.
July 20, 1912 (Address) 1601 /wework 4.
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.
19 PLACE OF BURIAL OR REMOVAL Edson Cemetery
DATE OF BURIAL
July 20, 192
(Informant)
Mr George H. Ingham
(Address)
North Chemsford
18
Filed
July 20, 1912 Edward & Robbing
REGISTRAR
20 UNDERTAKER
Заиновень.
ADDRESS
12 Hurd St
3 SEX
4 COLOR OR RACE
SINGLE, Since
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Male
White
7
1.8.9197
I HEREBY CERTIFY that I have investigated the
death of the deceased. The CAUSE OF DEATH* was as follows : accident (BOM RR)
(Truck by Train on grade Crossing)
multiple Traumatisme
9 BIRTHPLACE
(State or country)
Lowell Navs.
10 NAME OF
FATHER
George H. Ingham
PARENTS
11 BIRTHPLACE OF FATHER (State or country) England
12 MAIDEN NAME
OF MOTHER
Charlotte Havior
13 BIRTHPLACE
OF MOTHER
(State or country)
England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
important. See instructions on back of certificate.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH 1 PLACE OF DEATH On Track Both RR. Chelmsford (that) (No. School fr.
Ward)
49
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as 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- coma, etc., of .. (name origin: "Cancer" is less definite ; avoid uso of " Tumor" for malignant ncoplasms) ; Measles ; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "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 carbolic 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.
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 Juncelou Start Date Chisland St.
Mark In hall
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
8 SEX Mali
4 COLOR OR RACE
White
1 6 SINGLE,
MARRIED,
WIDOWED.
OR DIVORCEE
(Write the Royaled
16 DATE OF DEATH
7
20
(Month)
(Day)
(Year)
6 DATE OF BIRTH
(Month)
(Day)
....
(Year)
7 AGE
If LESS than
1 day, ........ hrs.
Or ........ min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work.
Cor Quaker
(b) General nature of industry, business, or establishment in which employed (or employer) ... ........ foundry
9 BIRTHPLACE (State or country) island
PARENTS
11 BIRTHPLACE OF FATHER (State or country) "Lesland
12 MAIDEN NAME OF MOTHER Célia
13 BIRTHPLACE OF MOTHER (State or country_ tiland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant):
1) mary highatte units
(Address)
Princeton stin chelusted
16 Filed. July 23, 1912 Edward &. Roffern 0 0
~ REGISTRAR .....
17
I HEREBY CERTIFY that I attended deceased from
June 5, 1912
₪ to
July 19, 19/2
that I last saw him alive on ....
July
$14, 1912
and that death occurred, on the date stated above, at ....... 0 ....... m.
The CAUSE OF DEATH* was as follows :
Head Disease
(Duration)
2 yrs.
ds.
mos.
Contributory ...
(SECONDARY)
.(Duration)
... yrs.
.. mos.
ds.
(Signed)
faut
M.D.
(Address) no elidnelong
* 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 ØR REMOVAL St tatueksterneley
DATE OF BURIAL July 28912
20 UNDERTAKER
ADDRESS
Hoeformell Down Sousel hass
Ward)
.......
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Registered No. 57
uncelon It Into Cheque seite
1136 Chelmsford (City or town.) .
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
I
..... .............. yrs. . ...
mos. ds.
10 NAME OF
FATHER
Tatuel ty Gath
....
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 engincer, 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 laborcr, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House-
keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain-
fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- 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 definito disease cau 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
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford (Ruth) (No. Crystal
hake
Poly E. arlin
131 Cashing h
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Married
1
(Year)
If LESS than
| day, ........ hrs.
ds.
or ........ min. ?
.a. Wilson &
Lowell Mass
10 NAME OF
FATHER
Charles arlin
11 BIRTHPLACE OF FATHER (State or country) Gilmanton n.H.
12 MAIDEN NAME
OF MOTHER
ann. Msc Clery.
New Hampshire
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mrs Sarah Urlin (wife)
(Address)
131 Cushing St
July 23, 1912 Edward Robbing
REGISTRAR-
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
21,
1912/
(Year)
(Month)
(Day)
17
I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
accidentil Imining
(Crystal Lake No. Chelmann)
(Duration)
ds.
mos.
Contributory ... (SECONDARY)
(Duration)
yrs.
mos. ds.
M.D.
(Signed)
hey 23. 1912
(Address) 160 Kumack 3
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.
19 PLACE OF BURIAL OR REMOVAL Edson Cemetery
DATE OF, BURIAL
July 24
1912
20 UNDERTAKER
ADDRESS
58 Prescott St.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
2 FULL NAME [If married or divorced woman or widow- give maiden name, also name of husband.] @RESIDENCE 3 SEX 4 COLOR OR RACE White Male 6 DATE OF BIRTH 7 AGE 30 VS. 10 .. yrs. mos. 8 OCCUPATION (a) Trade, profession, or (b) General nature of Industry, business, or establishment in which employed (or employer) ... 9 BIRTHPLACE (State or country) PARENTS 13 BIRTHPLACE OF MOTHER (State or country) 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 particular kind of work Jeamster
137
Cheli fund (Nach)
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
MARGIN RESERVED FOR BINDING
(Month) (Day)
Filed_ 0 0
.. yrs.
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. Bnt in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman,"" Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis ") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. ..... (name origir: "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. 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 carbolic 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.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
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.
PARENTS
New York
12 MAIDEN NAME
OF MOTHER
Sarah Smith.
13 BIRTHPLACE
OF MOTHER
or country) Salem Mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ....
James Cook
(Address)
1]. Smith St. Lowell Mass
15 Filed July 23, 1912 Edward &. Robbin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH July 21
(Month)
(Day)
1912
(Year)
I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
accidental
типид
(Crystal Lake he Chelnfund)
(Duration)
.yrs.
mos. ds.
Contributory ..
(SECONDARY)
(Duration) .yrs. .. mos. uds.
(Signed)
M.D.
Jak 2V, 1917 (Address) la thesnack h
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.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL Edwin Cemetery July 23, 1912
20 UNDERTAKER C.M. young
138 Cheli lund ( hath )
1 PLACE OF DEATH
Chelmsford (North)(No.
Crystal Lake
St.
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Grosse A. Cork
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 11 Smith St. Lowell Mass.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
Male
White
6 DATE OF BIRTH
Sept
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day, ........ hrs.
38 yrs.
mos. ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Courier:
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE (State or country)
Lowell Mass.
10 NAME OF
FATHER
James Cook.
11 BIRTHPLACE OF FATHER (State or country)
22
11874
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Registered No.
52
V ADDRESS
33 Prescott St
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as 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.
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