USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 18
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
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 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 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
.....
(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
4 COLOR OR RACE
male
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
november
07
(Month)
(Day)
1912
(Year)
6 DATE OF BIRTH
Olan.
(Month)
(Day)
-
(Year)
7 AGE
If LESS than
I day, ........ hrs.
... yrs. mos. ds.
a30 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)
) Harith Ghehuspod
(Duration)
.yrs.
mos.
ds.
10 NAME OF
FATHER
Gidion Gogmon
PARENTS?
12 MAIDEN NAME
OF MOTHER
alice Levoci
18 BIRTHPLACE
OF MOTHER
(State or country)
GanadaIf not at place of death ?
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
15 Filed 2200.12. 1912 Edward J. Jobbing
REGISTRAR
Contributory .. (SECONDARY)
(Duration)
yrs.
mos. ds.
72 Juney
M.D.
(Signed)
novel
1912
(Address) 21 Chilisfew Mas
* 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.
yrs.
mos.
ds.
Where was disease contracted,
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Mar 17 1912
20 UNDERTAKER
ADDRESS
738
A chichambault Merumort
important. See instructions on back of certificate.
1 PLACE OF DEATH
Laure
aurier
.
2 FULL NAME
Gogmar
[lf married or divorced woman or widow. give maiden name, also name of husband.] .... @RESIDENCE no. Chelmsford
Registered No.
73
MEDICAL CERTIFICATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
191
to
nov. 17
1912
....... .
that I last saw h we alive on
.,
1912
al bank
and that death occurred, on the date stated above, at ......
3 a. m.
The CAUSE OF DEATH* was as follows :
5
.......
11 BIRTHPLACE OF FATHER (State or country) Canada
159
St. :
....... Ward)
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 overy 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 (diseaso 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.
3 SEX male 7 AGE 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 ...
1 PLACE OF DEATH
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH Gast (No Chelmsford, Mass Still Born
St. :
Ward)
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also game of husband
@RESIDENCE
Gast Chilistool
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
m.27
19/2
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
100:27, 19/ 2/ 20
191
If LESS than
! day, ....
hrs.
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 :
(Duration)
.. yrs.
mos.
ds.
Contributory
(SECONDARY)
.(Duration) ..
2. 1 welch
... yrs.
.mos.
ds.
(Signed)
Nov 291012
(Address)
21 Panelo Alita
* If death followed injury or violence the certificate of death must be mbde 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
13 BIRTHPLACE OF MOTHER (State or country) Mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Chas. Jucraft
(Address)
in Thelobsterd
15 Filed 200. 27 1912 Edward & Loving
REGISTRAR
1
1
160 Chelmsford (City or own.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
74.
4 COLOR OR RACE
5 SINGLE
MARRIED
Single
WIDOWED,
OR DIVORCED"
( Write the word)
6 DATE OF BIRTH
27
(Month)
(Day)
1912
(Year)
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 county). Char Il traff
10 NAME OF FATHER Chas. He Zucraft Chas
11 BIRTHPLACE OF FATHER (Statc or country) maine
12 MAIDEN NAME OF MOTHER Sarah Emerson
Where was disease contracted, If not at place of death ? Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL 88. Jabricks
DATE OF BURIAL
nov. 27 1912
20 UNDERTAKER John J. OConnell 658 Johanna
MARGIN RESERVED FOR BINDING
-
ds.
....
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relativo healthfulness of various pursuits can bo known. The question applies to each and overy 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, Compositer, Architect, Loco- metive 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 naturo of tho 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) Cotten mill; (a) Sales- man, (b) Greeery ; (a) Fereman, (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 laberer, Farm laberer, Laberer - Coal mine, etc. Women at home, who aro ongaged in the duties of the household only (not paid Ileuse- keepers who receive a definite salary), may be entered as Housewife, Heusewerk, or At home, and children, not gain- fully employed, as At seheel or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service fer wages, as Servant, Ceek, Housemaid, etc. If the occupatien 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 Nene.
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 diseaso. 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 ") ; Lebar pneumonia ; Breneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc , Carcinoma, Sur- eema, etc., of. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Wheeping eeugh ; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent). affection aced not be stated unless in- portant. Example: Measles (disease causing death), 29 ds .; Brenche-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 septieaemia," " 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, Hemieide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Peisening, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons net disabled by recognized disease, as A death upon the street, er ene supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A persen 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, Youth Cheledord No , Neat fond ant
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
75-
PERSONAL AND STATISTICAL PARTICULARS
3 SEK
4 COLOR OR RACE
Steal Muito
6 SINGLE
MARRIEL
WIDOWED
OR DIVORCED anud
(Write the word)
& DATE OF BIRTH
- : 18ST ..
(Month)
(Day)
(Year)
If LESS than
1 day ......... hrs.
yrs.
mos.
ds.
....... 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)
Dufaud
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Queland
12 MAIDEN NAME
OF MOTHER
Mary ~ Jot Tum
13 BIRTHPLACE
OF MOTHER
(State or country)
Jufand
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
1) Mary MãDeath Daughter
(Address)
both Thelword
16 Filed 1200. 30, 1912 Edward J. Rotfin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
november
29
(Month)
(Day)
1912
(Year)
I HEREBY CERTIFY that I attended deceased from
Nor 3
1912 to
Mer 29
1912,
that I last saw h/ alive on
Non 27'
1912
and that death occurred, on the date stated above, at 29 m.
The CAUSE OF DEATH* was as follows : Cancer
(abdominal)
.
.(Duration) ....
yrs.
.mos.
ds.
Contributory
discreet heard of cedro
(SECONDARY)
(Duration) .
rot report ds.
JE Varney
M.D.
(Signed)
nor 29.
1912 (Address).
2. chefenfent
........
* 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 ...
In the
... 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
-
20 UNDERTAKER
ADDRESS
Yaus+ ORnewer no 324 May AVA.
1401 heleford
(City of town.)
.....
2 FULL NAME
the hutho
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
no Chelmsford
alec n. Cat /
MARGIN RESERVED FOR BINDING
10 NAME OF
FATHER
Gating Sh. Cal
17
7 AGE 15
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 caborer, 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 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 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 6. Gro hehusferd mass
St. :
Ward)
(City or town.) ! [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
74.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
If LESS than
I day, ..
.... hrs.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Carpenter
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Maine
PARENTS
12 MAIDEN NAME
OF MOTHER
anne Harmultor
13 BIRTHPLACE
OF MOTHER
(State or country)
Belevica
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
nelson. Fucraft,
(Address)
16 Filed. Acc. 4. 1912 Edward J. Rabbim
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
1
191.
2
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from Nov. 27, 19/2to Dec. 1 1912 ... .... that I last saw h mnalive on. Dec 1 1912 ....... , and that death occurred, on the date stated above, at .. m.
The CAUSE OF DEATH* was as follows :
(Pneumonia
(Duration)
.yrs.
.. mos.
5
ds.
Contributory (SECONDARY)
(Duration)
L.J. Welch
.yrs.
mos.
ds.
(Signed)
DEC3, 92 (Address).
2) Rurales Blog
* If death followed injury or violenee 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 Valueks
DATE OF BURIAL
Dec $ 1912
20 UNDERTAKER
ADDRESS,
2 FULL NAME
Charles. Loucraft
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE E. Chelmsford
162 (E. Chelmsford).
important. See instructions on back of certificate.
7 AGE 39
... yrs.
mos. . ds.
or ........ min. ?
10 NAME OF
FATHER
nelson J. Loucroft
11 BIRTHPLACE OF FATHER (State or country) Maine
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oceupa- 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, Loeo- 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 naturo of the business or industry, and therefore an additional lino 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 moro precise specifieation, as Day laborer, Farm laborer, Laborer - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may bo 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, ete. 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 "Epidemie ecrebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
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