USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 15
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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 cercbro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Łobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified. is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, otc., of. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough ; Chronic valvular heart disease; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," " Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite 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 Examinors :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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
Chelmsford
(No
North Rd.
Chelmsford (City or town.) Ward) fif death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
61
16 DATE OF DEATH
Seft 22
1912
....
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Sept 17, 1912, to
sept22
1912.
that I last saw her alive on.
Sept 22
1912
and that death occurred, on the date stated above, at 2369
The CAUSE OF DEATH* was as follows :
acute Enterocolitis
(Duration)
....
.. yrs.
mos.
9
ds.
Contributory.
(SECONDARY)
..... (Duration) ....
Rubanker
.yrs.
.......... 1
mos.
ds.
(Signed)
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.
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
Riverside Com.
no Reading
DATE OF BURIAL
Sebr 24.
1912
20 UNDERTAKER
Tratten Perham
ADDRESS
15 Filed. Sept. 23, 1912 Edward &, Rabbim
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
1910
(Year)
If LESS than
1 day, ........ hrs.
2FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
2%. Reading mary
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Hemale white
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
13
(Month)
(Day)
7 AGE
-
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)
To. Reading
10 NAME OF
FATHER
Chas, W. Overall
11 BIRTHPLACE
OF FATHER
(State or country)
try) Union Me
12 MAIDEN NAME
OF MOTHER
Helen b, sutton
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
Hoverft Me.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Tro Ches W. avenue
w.
important. See instructions on back of certificate.
(Address)
no, Reading
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
2
.yrs.
3
mos.
9
ds.
or ......... min. ?
Barbara averell
.
147
Act23, 192 (Address).
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, c. 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- mun, (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.
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; Chronie 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. 1
4. Deaths under circumstances unknown, as A person found dead, etc.
N B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
PARENTS
12 MAIDEN NAME OF MOTHER Regina Beandrea
18 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
church Av
File Sift 26 1912 Edward & Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
mal
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Jeps 25 0 2
(Month)
(Day) (Year)
6 DATE OF BIRTH Qua
(Month)
.
(Day)
-
(Year)
7 AGE
If LESS than
1 day, ........ hrs.
mos. 25 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) ...
I HEREBY CERTIFY that I attended deceased from
Sepas 02, 19/2, to
Sept 25, 1912.
that I last saw h alive on.
24
... 1912,
and that death occurred, on the date stated above, at 11Cm.
The CAUSE OF DEATH* was as follows :
Congenital Syphilis
(Duration)
yrs.
mos.
ds.
Contributory (SECONDARY)
.(Duration)
.... yrs.
mos.
ds.
(Signed)
M.D.
304425, 1919 (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.
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 If yough
DATE OF BURIAL
Sel/2/09/2
ADDRESS
738
20 UNDERTAKER
of Archambaud queismert
14.8
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
North Chelunford.
Church
St. : Ward)
(City or town.) Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
George od. Galbat
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Church 2l
Registered No.
62
PERSONAL AND STATISTICAL PARTICULARS
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
9 BIRTHPLACE
(State or country)
Harth Chehuske
10 NAME OF
FATHER
Brita Talbot
11 BIRTHPLACE OF FATHER (State or country)
...
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 taborer, 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 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 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 PLAGE OF DEATH Darth Ghehuch and Wood Earnest
Ward)
Abraham allard .......
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Good Banner/
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
mal
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Wrie the word)
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
82
yrs.
mos.
* ds.
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
Tough allard
PARENTS
12 MAIDEN NAME OF MOTHER antoinette Berna
13 BIRTHPLACE OF MOTHER (State or country)
Barradi
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Mood barner
16
Filed
Oct. 4, 1912 Edward J. Roffing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
2
(Month)
(Day)
191.
(Year)
...
If LESS than
1 day ........
..... hrs.
that I last saw hw alive on
Cal-1
19/2
, and that death occurred, on the date stated above, at 7/5ml/ The CAUSE OF DEATH* was as follows :
Pulmonary tuberculosis
not. Kurum
.
(Duration)
... yrs.
...
.mos.
ds.
Contributory .. (SECONDARY)
(Duration)
... mos.
ds.
(Signed)
JE Vamer
.... yrs.
.
M.D.
· Del. 2.
1912 (Address)
H. Chichesterl.
* If death followed miury 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
of death
x .... 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
1912
20 UNDERTAKER Atlichas
ADDRESS 738
pe;
important. See instructions on back of certificate.
14.9
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
63
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
1820
17
I HEREBY CERTIFY that I attended deceased from
Geht. 8
.....
1912, to
.........
Del-2
1912
....
11 BIRTHPLACE OF FATHER (State or country)
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 Scrvant, 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 (retircd, 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 discase; 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
Chelmsford
(No
"till bow Marshall
St. :
Ward)
(City or Bwn.) [If death occurred in a hospital or institution, give its NAME instead of street and number.}
2FULL NAME. [If married or divorced woman or widow give maiden name, also pame of husband.] @RESIDENCE Chelmsford mars
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
G DATE OF BIRTH
Sept.
27
(Monthı)
(Day)
1912
(Year)
7 AGE
If LESS than
1 day ......... hrs.
.. yrs.
0
mos.
G
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. mars.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
> Lewvielen, me.
12 MAIDEN NAME
OF MOTHER
Emma Holt
13 BIRTHPLACE
OF MOTHER
West Chelmsford Maspit not at plac
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mr. marshall
(Address)
Chelmsford, inc.
15 Filed Sept. 28, 1912, Edward ), Rolling
REGISTRAR
10 DATE OF DEATH
-
(Month)
(Year)
17 I HEREBY CERTIFY that I attended deceased from Sept. 27, 1912, to. Sept 27, 1912 that I last saw her alive on. Sept. 27, 1912 and that death occurred, on the dato stated above, at. ..............
.m.
The CAUSE OF DEATH* was as follows :
Premature -
1/2 hour.
(Duration)
.. yrs.
mos.
ds.
Contributory (SECONDARY)
.. (Duration)
....... yrs.
mos.
ds.
Autre 9. Soboria
M.D.
(Signed)
Sept. 27, 1912 (Addres
Chelmsford, mais
* 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.
. ............ mos. .
In the
ds.
.......... ....
Where was disease contracted,
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Sept 28
1912
Chetwinful.
20 UNDERTAKER
Walter Tecken
ADDRESS
Elelunsford.
Chelmsford 150
-..
Registered No.
64
MEDICAL CERTIFICATE OF DEATH
(Day)
191
2
10 NAME OF
FATHER V
fiscale E. Marshall
....
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, irrespectivo of agc. 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 Nonc.
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