USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 14
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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, peritonaeum, 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 " (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 septicemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under tho 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.
3 SEX Female AGE PARENTS important. See instructions on back of certificate. 16 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 Commmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No
Vickery
Stillon)
2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
( Write the word)
6 DATE OF BIRTH
21
1412
(Month )
(Day)
(Year)
If LESS than
| day, ....... hrs.
O
.. yrs.
mos.
0
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)
Chelmsford
10 NAME OF
FATHER
Elmex W. Vickery
11 BIRTHPLACE OF FATHER (State or country) Roxbury
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ...
Elo Vickery
(Address)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Aug.
21
(Month)
(Day)
1912
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Any. 21
1912 to
Ang, 21,
1912
.......
that ! last saw h.
.....
alive on ...
191
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Sielbom -
(Duration)
........
.yrs.
mos.
ds.
Contributory ...
(SECONDARY)
(Duration),
.. yrs.
mos. ... ds.
(Signed)
Auchun G Serena,
M.D.
Ana, 21, 1912 (Address).
Chelmsford, Maso.
* If death followed injury or violence the certificate ef 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.
.. mos.
ds ...
.........
Where was disease contracted, If not at place of death ?.
Former or usual residence. ........
19 PLACE OF BURIAL OR REMOVAL Horefather Com
DATE OF BURIAL
aug 21, 1912
* UNDERTAKER
WalterPerham
ADDRESS
Chelmsford
14.3
(City or town.)
Tif death occurred in a hospital or institution, give its NAME instead of street and number.]
St. :
Ward)
Registered No.
57
4 COLOR OR RACE
white
Filed .. 191.
....
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of eccupa- 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 en the first line will be sufficient, o. g., Farmer or Planter, Physician, Compositor, Architeet, 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 nceded. 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 Ilousewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should bo 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, tho DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," 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 .; Broneho-pneumonia (secondary), 10 ds. Never report inere 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 ef 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 lisease, as A death upon the strcet, 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
(No North Sr.
St. :
Ward)
(City or town.) Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
58
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Tale
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
6 DATE OF BIRTH
Sept
24 1838
(Month)
(Day)
(Year)
7 AGE
73
grs.
11
mos.
5
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Harmer
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Chelmsford.
PARENTS
12 MAIDEN NAME
OF MOTHER
Mary Richardam
13 BIRTHPLACE
OF MOTHER
(State or country)
chelated
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mro E.T. Parker
(Address) Chelmsford
15 Sept.1 1912 Edward Dollars Filed
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
29
1912
(Year)
17
I HEREBY CERTIFY that I attended deceased from
aug. 1800
., 1912, to
aug. 29
..... 19|2
that I last saw him alive on.
aug. 29
. 1912,
and that death occurred, on the date stated above, at //Qm.
The CAUSE OF DEATH* was as follows :
Continitio
' (Duration)
.
.. yrs.
mos. //
„ds.
Contributory (SECONDARY)
(Signed)
masa Howard
7yrs.
mos.
ds
aug 29
1912 (Address).
Chelmsford.
...
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).
In the
At place
of death.
... yrs.
mos.
.ds.
State.
yrs.
.mos.
ds ...
Where was dlsease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Forefathers Com
DATE OF BURIAL
Sept 1, 1912
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
144
FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
Edward thancie Parken
1
(Month)
(Day)
If LESS than [ day, .. hrs.
10 NAME OF
FATHER
Thaneis P. Parker
11 BIRTHPLACE
OF FATHER
(State or country)
Chelmsford
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 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, peritonacun, 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 widertaken.
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.
3 SEX male 7 AGE T 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 Ummmmmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
Chilmalo
for
Center
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
6636
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Soft,
15
2
....
...
(Month)
(Day)
191.
(Year)
6 DATE OF BIRTH
aug.
10th
1911
(Month)
(Day)
(Year)
If LESS than
[ day ......... hrs.
..... yrs.
1
.... mot.
8 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)
Chelmsford Center.
10 NAME OF
FATHER
Mumla Tremblay
11 BIRTHPLACE
OF FATHER
(State or country)
Canada
12 MAIDEN NAME
OF MOTHER
Ida Germain
18 BIRTHPLACE
OF MOTHER
(State or country)
Canada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mumba Tremblay
(Address)
Chelmsford Under
Filed __ Seft. 19 1912 Edsfand L. Robbing
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from Soft. 15, 1913 to Saft. 18 1912
......
..........
that I last saw hamalive on ..
......
Soft 15
1912
.......
and that death occurred, on the dato stated above, at.
.........
m.
The CAUSE OF DEATH* was as follows :
Inemmaria
...
(Duration)
.. yrs.
mos.
6 ds.
Contributory ...
Enteritis
(SECONDARY)
...... (Duration)
yrs.
mos.
ds.
(Signed)
ALavallée
M.D.
-
Self-18, 1912 (Addres).
790 kurss st,
........
* 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
Sept 19 1912
2 UNDERTAKER Joseph albert
ADDRESS
17 1 arken the
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
'FULL NAME
Harry Tremblay
[If marricd or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
145
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-
Dr Lavallée.
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.
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 Oto Chelmsford IN
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male White
4 COLOR OR RACE
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
aug. 27 25
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day ......... hrs.
mos.
2/ ds.
or ........ min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
Nothing
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Hr. Chelmsford. Mas
PARENTS
12 MAIDEN NAME
OF MOTHER
Endlich 9. Rushworth
13 BIRTHPLACE
OF MOTHER
(State or country)
Lowell. Mass.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Char Fr. Hoelgel
(Address)
220. Chelmsford
15 Sept. 18,1912 Edward . Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sell-
17
.... .
1912
(Month)
(Day)
(Year)
19/2 17 1 HEREBY CERTIFY that I attended deceased from
-491
to
Soll. 17
192
that I last saw hw alive on
1912
and that death occurred, on the date stated above, at 10 fim.
The CAUSE OF DEATH* was as follows :
Presedine bisch
(Duration)
......
.. yrs.
mos.
ds.
Contributory (SECONDARY)
.. (Duration).
.yrs.
FE Varney
.mos.
ds.
(Signed)
L21-18
... .
1912 (Address).
I, Chilietfest.
.....
* 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
Riverside Center Soft1 87/1912
20 UNDERTAKER
I S'NATTEN
ADDRESS
220. Chelmsford
Tr
Filed
Saveur.
Frederick Hocker
2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE No Chelmsford
146
MARGIN RESERVED FOR BINDING
10 NAME OF
FATHER
Char Fr. Hochel
11 BIRTHPLACE
OF FATHER
(State or country)
Methyen. Masa
M.D.
...
Registered No.
60
.. yrs.
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 needcd. 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 aro 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.
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