USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 13
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
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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; 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 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."
1
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.
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 720 chelmsford (No Boston Road Ward)
139 No. Chel (City-town.)
ford
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
53
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female.
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED.
OR DIVORCED
(Write the word)
1 Single.
6 DATE OF BIRTH April (Month)
21.
1912,
17
(Day)
(Year)
7 AGE
If LESS than i day ......... hrs.
yrs. 3 mos. /5-ds.
........ 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).
At Home
9 BIRTHPLACE
(State or country)
No. Chelmsford, Mack.
PARENTS
11 BIRTHPLACE OF FATHER Make or country) No. Chelmsford, Mace.
12 MAIDEN NAME
OF MOTHER
Cara M. Shattuck.
13 BIRTHPLACE
OF MOTHER
(State or country)
Graniteville Mare
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
distracted It, Mc Emanas
(Address) No. Chelmsford,
0
16 Filed Divy 6, 1912 Edward Groot fin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Aux
(Mouth)
(Day)
1912
(Year)
I HEREBY CERTIFY that I attended deceased from
30
. 1912, to
191
that last saw hon ... alive on .....
191 2, and that death occurred, on the date stated above, at 10.45 Am The CAUSE OF DEATH* was as follows :
(Duration)
......
yrs.
.mos ..
ds.
Contributory (SECONDARY)
(Duration) yrs.
mos. ds.
(Signed)
M.D.
1912 (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. HarvierCemetery Westford Mask,
DATE OF BURIAL
Aug, 6, 1912.
20 UNDERTAKER
Grom Healey
ADDRESS
79 Branch &x.
In. Zaban.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
2 FULL NAME
Ruth A. Mc Enaney
-
[If married or divorced woman or widow give maiden name, algy name of husband.] @RESIDENCE Boston Road.
0
.
10 NAME OF
FATHER
Sylvester H.Mc Enaney.
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 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, peritonacum, etc., Carcinoma, Sar- coma, etc., of ..... .. (name origin: "Cancer" is less definito; 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 " (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 deathis 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
140
Lowell
(City or town.)
fif deeth occurred jn 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
Pike Place Chelmsford mars.
Registered No.
1171
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
While
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1
Mand
6 DATE OF BIRTH
Sib
30
1839
17
(Month)
(Day)
(Year)/
7 AGE
If LESS then
I dey, ....... hrs.
72 yrs. 10 mos. 8 mos. ds.
or ........ min. ?
8 OCCUPATION
(a) Trede, profession, or
particular kind of work.
Retired
(b) General nature of industry.
business, or establishment in
which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Orveden
10 NAME OF
FATHER
nils Aventin
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Sweden.
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
nils Nelson. 12
(Address)
18 Ung 12 1912
REGISTRAR
16 DATE OF DEATH
Cina
1912
(Monthy
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
191
to
191
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 :
accident (istauch try andinitomobile)
1
(Duration) 0 yrs. 6
ds.
Contributory
(SECONDARY)
Inwine( Duration).
mos.
ds.
I. T. Murs med Cy
(Signed)
....
, ... .
M.D.
Una 8 19 2 (Address) i Dowell Mille
* 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 Westlawir Con.
DATE OF BURIAL
Cing 11 1912
20 UNDERTAKER
Manito. Sarmatur.
ADDRESS
1) Hund It,
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH Laval mais. (No. Chelmsford It Nost.
Svin Nelson
St. :
Ward)
MEDICAL CERTIFICATE OF DEATH
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 - Coul 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 employcd, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servunt, 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- comu, 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 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, E.c- 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.
3 SEX Male 7 AGE PARENTS important. See instructions on back of certificate. 18 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
North Chelmsford. ....... (No .......... Dunstable ..... Road.
St. ;...................
Ward)
'FULL NAME ........ Frederick .... Mallalieu. [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Dunstable Rd, North Chelmsford.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
5 SINGLE,
MARRIED.
WIDOWED
OR DIVORCED
(Write the word)
Married
White
6 DATE OF BIRTH
July 25 18.4.417 (Year)
(Month)
(Day)
If LESS than
[ day .......... hrs.
68 yrs.
... mos. 1.9 .... ds.
......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Spinner ...
(b) General nature of industry, business, or establishment in which employed ( or employer) ...
9 BIRTHPLACE
(State or country)
England
10 NAME OF
FATHER
John Mallalieu.
11 BIRTHPLACE OF FATHER (State or country) England
12 MAIDEN NAME
OF MOTHER
Alice Brierley
13 BIRTHPLACE
OF MOTHER
(State or country)
England
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mrs. Frederick Mallalieu
(Address) Dunstable Rd. No. Chelm.
Filed. any. 17, 1912 Edward: Robbins
REGISTRAR
...
(Month
13,, 1912 (Day) (Year)
r
Queg 13
1912.
, to.
that I last saw hun alive on.
ang 13
..............
1912 and that death occurred, on the dato stated above, at 9.30 an The CAUSE OF DEATH* was as follows : Empresa of Fall-Hadde
3 marks
(Duration) ...
......
.yrs.
.moso.
.ds.
Contributory.
Organic deseamy head
..... (SECONDARY)
.. (Duration)
.mos. ds.
(Signed)
+ E Tammer
.
M.D.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ...
... yrs. ............ mos.
........
.....
In the
ds.
State.
..... yrs.
mos.
.....
Where was disease contracted,
.
If not at place of death ?.
Former or usual residence ... ......
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Riverside Cem ha Chel aug 17, 1912
20 UNDERTAKER
Chas m. young.
ADDRESS
33 Prescott St
141
.... (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
55
16 DATE OF DEATH
aug
...
I HEREBY CERTIFY that I attended deceased from
Gug 9
.
......................................
1912 (Address)
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- 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 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 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.
2 FULL NAME [If married or divorced woman of widow give maiden name, also name of husband.] @RESIDENCE 3 SEX 4 COLOR OR RACE male 6 DATE OF BIRTH aug (Monthly 7 AGE - 8 OCCUPATION (a) Trade, profassion, or particular kind of work. (b) Genaral nature of industry, businass, or establishment in which employad (or employer) .. 11 BIRTHPLACE OF FATHER (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 .... ........................... yrs. .... mos.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford Centro Smith are
.St .;
Ward)
[If death occurred in a hospital or institution, give its NAME instead of streat and number.]
Joseph albert S. Vramblay
Medinavi St Rear Smith are Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
august
19
1912
(Month)
(Day)
(Year)
...
I HEREBY CERTIFY that I attended deceased from
august 12 1912 to.
august1992
-
that I last saw humalive on.
anal 12
1912
and that death occurred, on the date stated above, at.
.......
.. m.
The CAUSE OF DEATH* was as follows :
Enteritis
(Duration).
- yrs ..
)
.... mos.
12
ds .
Contributory .
(SECONDARY)
(Duration) .
yrs.
** mos.
ds
(Signed)
GoLavallée MD.
aug 19, 1912 (Address)
790 Men KI, La
M.D.
Laurel
- 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.
Stata.
In tha
.. yrs.
.mos.
ds.
Where was disease contracted, Af not at place of death ?.
Former or usual residence ........ ....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
au/1999
(Address) Chelmsford Tas
16 Filed __ Any, 19, 1912 Edward J. Rolfing
1 REGISTRAR
-
(Day)
.. (Year)
If LESS than
I day, ....... hrs.
or ........ min. ?
9 BIRTHPLACE
(State or country)
Chelmsford A
10 NAME OF
FATHER
George Chambre
12 MAIDEN NAME
OF MOTHER
alice Marini
Lawell Ma
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
George Uramblay
20 UNDERTAKER
ADDRESS
738
142
(City or town.)
56
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
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 cngincer, 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- 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.
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