USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 16
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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 ") ; Eobar 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 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," ctc.), "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 discascs 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.
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
North Chelmsford Mass No. 2014 Middlesex
St. ;.................. .Ward)
(City or town.) fif death occurred in a hospital or institution, give its NAME instead of street and number.]
'FULL NAME James .... W .... Moore .. [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 2014 Middlesex St.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
Male
White
6 DATE OF BIRTH
Feb. 2
18.35
(Month)
(Day)
(Year)
7 AGE
If LESS than ' day ..........
77
yrs. mos. ds.
Or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work .....
Reti ... r.s.d.
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Belfast, Treland
10 NAME OF
FATHER
Edward Moore
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Treland
12 MAIDEN NAME
OF MOTHER
Charity Carlisle.
13 BIRTHPLACE
OF MOTHER
(State or country) Treland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. Nellie E Prince.
(Address) 2014 Middlesex St.
15 Filed Oct- 14, 1912 Edward S. Robbing .....
REGISTRAR
18 DATE OF DEATH
Oct. 11
, 1912
....
(Month)
(Day)
(Year)
= I HEREBY CERTIFY that I attended deceased from Cung 8 ......
-
1912
..... , to
Cel- 11. 19/2
that I last saw halive on.
Oct- 11
1912
and that death occurred, on the dato stated above, at 445 m.
The CAUSE OF DEATH* was as follows :
Centerio selervai
...
.... (Duration)
............. yrs.
mos. ds.
Contributory
Similil
.... (SECONDARY)
(Signed)
JE Vaney
M.D.
001.12 1912 (Address)
H. Chefunfund
* 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 .....
1) PLACE OF BURIAL OR REMOVAL
Littleton mass
DATE OF BURIAL
Oct 14, 1912
20 UNDERTAKER Charles m. young
ADDRESS
33 Prescott St
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
Registered No.
65
North Chelmsford Mass
151
(Duration) . .............. yrs.
............... mos. .............. 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 engincer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged 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 " (mcrely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State canse 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 onc 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
West Chelmsford
(No St. :
Ward)
Paul Edmond Johnson
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Short Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,-
WIDOWED,
OR DIVORCED
( Write the word)
Single
16 DATE OF DEATH
Oct.
15
1912
.....
(Month)
(Day)
(Year)
6 DATE OF BIRTH
Chr.
/Month)
16
.,
1912
(Year)
7 AGE
If LESS than
1 day, ........ hrs.
yrs.
6
mos.
ds.
or ......... min. ?
$ 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) Hast
try Heet Chelmsford
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Sweden
12 MAIDEN NAME
OF MOTHER
Ellen Sophia Limburg
13 BIRTHPLACE
OF MOTHER
(State or country)
Sweden
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address) Jest Chelmsford Mars.
Filed. Oct. 16, 1912 Edward J. Robbing
....
REGISTRAR
(Duration).
yrs.
2
mos.
ds.
Contributory ..
Lobal Pneumonia
(SECONDARY)
.. (Duration)
.yrs.
mos.
ds.
(Signed)
1. 2. Wells
M.D.
Oct. 15
1912 (Address) Hartford 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.
in the
.mos.
ds ...
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Hast Chelmsford
DATE OF BURIAL
(Cet. 17
1912
20 UNDERTAKER
Acting az Undulates
ADDRESS
Fest Chelmsford
---
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
152 Chelmsford (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
66
17
I HEREBY CERTIFY that I attended deceased from
Oct. 13
....
1912
..... , to
Oct. 15
191Z.
.......
...
that I last saw be alive on
Oct. 15
1912
...
and that death occurred, on the date stated above, at 2 P.m.
The CAUSE OF DEATH* was as follows :
Meningitis (Pneumococcus)
3
10 NAME OF
FATHER
John & Johnson.
(Day)
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 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 dcad, 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 Lirvell mars. (No. Lowell Jenl. bush
.
St. :
Ward)
[if death occurred in a hospital or institution, give its NAME Instead of straet and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE
While
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Hidowed
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
If LESS than 1 day, ....... hrs.
yrs.
mos.
8.
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Retired "merchant
(b) Ganeral natura of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Ceptwell "mars.
10 NAME OF
FATHER
Isaac Himship
Isac
PARENTS
11 BIRTHPLACE OF FATHER (State or country) mason n. R.
12 MAIDEN NAME
OF MOTHER
may march.
13 BIRTHPLACE OF MOTHER (State or country)
Cistiby mars.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
15
Filad ..
Och.
19/2.
1
REGISTRAR
153
Lowell
(City or town.)
...
marcus H. Hinship mshub
2 FULL NAME
{If married or divorced woman or widow,
give maiden name, also name of husband.j .. /2.
@RESIDENCE
West Strelunsford mais
16 DATE OF DEATH
Oct.
(Month)
(Day)
1912. (Year)
COUNTER
1912
„ to
191
1
that I last saw hmm alive on 191 .. and that death occurred, on the date stated above, at. „m.
The CAUSE OF DEATH* was as follows : 1
Following Grantalictony
(Duration)
... yrs.
. .....
mos.
ds.
Contributory .. (SECONDARY)
(Duration)
$ 1 .
mos.
ds.
8. Cultur Page
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 tha
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 It. Chelmsford mars.
DATE OF BURIAL
Oct 10 1912
20 UNDERTAKER
A.a. Hein buch
ADDRESS
16 market Rt
67 $414
Registered No.
A
2
2
63
30
164.017
I HEREBY CERTIFY that/I attended deceased from
(Signed)
, 1902
19
.... ' (Address).
64 Mental 21.
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 inaterial 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 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. - Nanie, 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 fevcr (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, Sur- eoma, 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.
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Ummmmmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
North Chelmsford Mas(No.
St. : Ward)
... (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
68
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Oct
29
.. ,
1912/
(Year)
Male
White
6 DATE OF BIRTH
(Month) (Day)
18.327 (Year)
If LESS than
[ day .......... hrs.
80
.... yrs. .. mos.
ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Farmer
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
England
10 NAME OF
FATHER
Unknown
11 BIRTHPLACE OF FATHER (State or country)
England
12 MAIDEN NAME OF MOTHER
Unknown
18 BIRTHPLACE OF MOTHER (State or country) _Unknown
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) John Bridzford
(Address)
North Chelmsford Mass.
15 Filed Oct. 31, 1912, Edward S. Rotting
REGISTRAR
.. (Duration)
................. yrs.
.. mos ..
7
ds.
senility
N
Contributory
.... (SECONDARY)
(Duration) . ............ yrs.
.. mos. ds.
...........
M.D.
(Signed)
Cel-30
.....
1912 (Addre
M. Chickenfind
* 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.
Where was disease contracted, If not at place of death ?..
............... ........... Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
Worth Chelmsford
DATE OF BURIAL Oct. 3%, 1912
20 UNDERTAKER Chas. M. Young
ADDRESS
53 Prescott St.
3 SEX 7 AGE PARENTS CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ...
4 COLOR OR RACE
5 SINGLE,
MARRIED
WIDOWED,
married
OR DIVORCED
(Write the word)
(Month)
(Day)
I HEREBY CERTIFY that I attended deceased from
Qel. 24, 1912, to
Ref. 29
........ ,
192
....
that I last saw h w alive on.
Qel-29
........
...........
1912
and that death occurred, on the dato stated above, at 7Pm.
The CAUSE OF DEATH* was as follows :
Pneu mena
.....
.. ds ... .........
2FULL NAME. Thomas ..... Bridgford {If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE North Chelmsford Mass
154
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 (6) 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.
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