USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 17
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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, peritonacum, 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 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.
3 SEX Female 7 AGE 8 OCCUPATION PARENTS (Informant) important. See instructions on back of certificate: (Address) Filed 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 Commwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford
(No
Actor Fr.
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
69
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Oct.
.
(Month)
(Day)
1912
(Year)
17 I HEREBY CERTIFY that I attended deceased from
1911 to
Oct
191
191.
.,
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
habites mellitus
Several
(Duration) 1 yrs.
mos.
ds.
Contributory. (SECONDARY)
(Duration) .
0 yrs.
mos.
ds.
Autre J. Scobona
M.D.
(Signed)
/012, 92 (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
1 PLACE OF BURIAL OR REMOVAL Pine Ridge Com.
DATE OF BURIAL
Nov 2, 1913
20 UNDERTAKER
H. Perhaus
ADDRESS
18 2200. 2 1912 Educa awards. Robbing
REGISTRAR
5 SINGLE,
MARRIED
Married
WIDOWED
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Oct
12
18.45
(Montlı)
(Day)
(Year)
If LESS than
I day. .......
hrs.
that I last saw h
alive on
67 yrs. 0
mos.
19 ds.
or ........ min. ?
(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)
England
10 NAME OF
FATHER
Lazers Silent
11 BIRTHPLACE OF FATHER (State or country) England
12 MAIDEN NAME
OF MOTHER
Mary Barnes
13 BIRTHPLACE
OF MOTHER
(State or country)
England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
2FULL NAME
amelia Elliott
{If married or divorced woman or widow
give maiden name, also name of husband.] .
@RESIDENCE
Chelmsford
amelia Silvy John Elliott
155
L
4 COLOR OR RACE
White
31
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 sccond 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 dutics 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, Hlouscmaid, 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 fcvcr (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., Careinoma, 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 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 Lowell Hass .(No. 151 Wichtman
St. ; Ward)
156 Lowell (City or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
'FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Etta Hoall: Robert Gunston.
151 Wightman St.
Registered No. 70
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
4 COLOR OR RACE
Female White
1 5 SINGLE,
MARRIED,
Widow
WIDOWED,
low
(Write the word)
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
-
If LESS than
1 day .......... hrs.
64
..... 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)
Waterford Vermont
PARENTS
12 MAIDEN NAME
OF MOTHER
Emily Morrell
13 BIRTHPLACE
OF MOTHER
(State or country)
Vermont
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mr James a. Hadley
(Address)
16 Filed 200.12. 1912, Edward SeRottung
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
november
11ª
1912
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
........ , 19 1_
nor 11ª
1912
that I last saw h alive on.
Her 11
1912
........
and that death occurred, on the dato stated above, at ..
//a.m.
The CAUSE OF DEATH* was as follows :
My xoedenca
....
Several years
..... (Duration)
.......
..... yrs.
mos,
ds.
Contributory. (SECONDARY)
.. (Duration) .
................ yrs.
mos.
ds.
(Signed)
JEVany
M.D.
... , 1912 (Address).
Michele fest
* 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.
de.
State ............ yrs.
............ mos.
ds ........
.........
....
In the
Where was disease centracted, If not at place of death ?...
Former or usual residence ...
19 PLACE OF BURIAL OR REMOVAL St. Johnsfun Derma
DATE OF BURIAL
1912
" UNDERTAKER
4.03. Bustier 60
ADDRESS
58 Prescott St
...........
...............
....
10 NAME OF
FATHER
Josiah Hadley
11 BIRTHPLACE OF FATHER (State or country) Waterford Ut
Etta
H. Hunston
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, 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 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.
'FULL NAME 6 DATE OF BIRTH 7 AGE PARENTS important. See instructions on back of certificate. (Address) 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
PLACE OF DEATH Chelmsford (No. Chelmsford
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Char
Ollen Coburn
Castand Mary Sauroy: Leny Coburn
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
Lemale awhite
6 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
Widowed
1
(Year)
If LESS than
t day .......... hrs.
70 yrs.
yrs.
mos. 22 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)
"Westminster Mass
10 NAME OF
FATHER
Karles Sawyer
11 BIRTHPLACE
OF FATHER
(State or country)
Unknown
12 MAIDEN NAME
OF MOTHER
Chelegenda Cobb
13 BIRTHPLACE
OF MOTHER
(State or country)
0 Unknown
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Offre Mary B. charge PLACE OF BURIAL
16 Filed_ Jom 16, 1913 Edward J. Robban
.........
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from c/Nov. 14, 1912 to choo 14. 19/2 ...... that I last saw her alive on 0/100 14 1912 and that death occurred, on the dato stated above, at 7:00pm
The CAUSE OF DEATH* was as follows :
Diabetes
.
.(Duration) ...........
YES,
.... mos.
ds.
Contributory
Dedeux of Langs
(SECONDARY)
... (Duration) .
yrs.
2
.mos.
................
ds.
(Signed)
Yeah, You Deursen
M.D.
Mor 16, 1912 (Address) 17 Kinks8.
* 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
In the
of death
.... yrs.
. ............ mos. ............
ds.
State ...
ds
............ yrs.
............ mos.
Where was disease contracted,
if not at place of death ?........ .... Former or usual residence .. .... --
OR, REMOVAL
Lowell Demeters Nov 17, 1912
DATE OF BURIAL
1.03. CurrierSo 38 Lescol Df
-
-
16 DATE OF DEATH
Nov. 14
1912
(Month)
(Day)
(Year)
(Month)
(Day)
157
(City or town.)
[If married or divorced woman or widow give maiden name, also name of husband.y. @RESIDENCE
Chelmsford
Registered No. 71
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, 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 childhirth 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 he 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
1
158
(City or town.)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
& SEX
female
4 COLOR OR RACE
rolite
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Ringte
6 DATE OF BIRTH
7
1894
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day ......... hrs.
.yrs.
6
... mos. ....
ds.
9
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)
720. Shelausford, Mas
10 NAME OF
FATHER
Charles F.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Lowell , Mace.
12 MAIDEN NAME
OF MOTHER
Bertha 6. Beaker
13 BIRTHPLACE
OF MOTHER
(State or country)
No. Chelmsford, Mais
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
C. E. Scobrar
(Address)
no chelmsford.
Filed
16 2200.19, 1912 Edward . Robin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
nos 16.
191 2
(Month)
(Day)
(Year)
17
1 HEREBY CERTIFY that I attended deceased from
Ca 10
Her 16
1912 to
1912
....
that I last saw her alive on.
Ner 16
192
....... .
and that death occurred, on the date stated above, at 2.30pm.
The CAUSE OF DEATH* was as follows :
Cendo carditis
.. (Duration)
3
yrs.
.mos.
ds.
Contributory.
Rheumatism
(SECONDARY)
(Duration)
6
.... yrs.
.mos.
ds.
(Signed)
JE Vaney
M.D.
Mer 17.
1912 (Address)
H. Chilwanted.
...
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
. yrs
... mos.
in the
.. ds.
State ...
... yrs.
.mos.
ds.
Where was disease contracted, If not at place of death ?. ...
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL no. Chelmsford.
DATE OF BURIAL
7250. 19. 1912
20 UNDERTAKER She a. Weinbeck
ADDRESS
V6 Market St.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH 76. Chileno Lord (No.
St. : Ward)
Ruth Mildred Sonibrie
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Me. Chichen ford, Ilare ..
Registered No.
72
MARGIN RESERVED FOR BINDING
·
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 returu "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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