USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 19
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culosis of lungs, meninges, peritonaeum, etc , Carcinoma, Sar- coma, etc., of ... ..... (namo origin: "Cancer" is less definite ; avoid use of "Tumor " for malignant neoplasms) ; Measles; Whooping cough; Chronie 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 .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Scnile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," " Old ago," "Shoek," " Uraemia," " Weakness," etc., when a definite disease ean be ascertained as the eause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septiedemia," "PUERPERAL peritonitis," etc. State eause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under tho provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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 DEATA North (Select ford) (No. ..... Church Street
St. :
163 (Reluct ford Das Ward) (gity or town,y {If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Church Ut
forth Chelui fond Registered No. 77
MEDICAL CERTIFICATE OF DEATH
3 SEX
Mal Dito
.
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
watedward
yourd
5/DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
1 day ......... hrs.
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)
Queland
PARENTS
12 MAIDEN NAME
OF MOTHER
Catherine Hughes
18 BIRTHPLACE
OF MOTHER
(State or country)
Drefand
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address) worth Cheles ford has
16 Filed. Dec. 4 , Edward Robbing
REGISTRAR
16 DATE OF DEATH
12
3
(Month)
(Day)
1912
.....
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Não 12, 1912, to.
Dec 3, 19/2.
that I last saw him alive on
Que 3
, 1912.
and that death occurred, on the date stated above, at 11 a m.
The CAUSE OF DEATH* was as follows :
Chu. Bronchitis
.(Duration) .
3
.... yrs.
......
.mos.
ds.
Contributory.
Senile Debility
.... (SECONDARY)
(Duration)
.. yrs.
.mos.
......
ds.
(Signed)
James fi taban
M.D.
..... , 191 ........ (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. ....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
191.2
.......
20 UNDERTAKER
null
Queter
ADDRESS 23 24 market vf.
MARGIN RESERVED FOR BINDING
10 NAME OF
FATHER
11 BIRTHPLACE OF FATHER (State or country)
Queland
....
PERSONAL AND STATISTICAL PARTICULARS
67,
.... yrs.
.mos.
ds.
or ......... min. ?
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 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
1 PLACE OF DEATH north Chelm fund
STANDARD CERTIFICATE OF DEATH on track of BIM RR. (No. Butun Wocheles Med Tyngaltro Ward)
Laley .... (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME William & Furni
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
8 Rimeren Av.
Registered No.
78
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
Male. White
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single.
6 DATE OF BIRTH
March
(Month)
(Day)
1.
1869
(Year)
7 AGE
If LESS than
1 day ...
.. hrs.
43 yrs. 9 ms.
4
.ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ....
Landscape Gardner
(b) General nature of industry,
business, or establishment in
Landscape Gardner.
.... (Duration)
... yrs.
.mos.
ds.
Contributory ..
Multiple Traumatismo
(SECONDARY)
(Duration) .
yrs.
.mos. ds.
M.D.
(Signed)
Die 7, 1912/
(Address) ...
160 Rumbach Li
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
. mos.
ds.
State
.yrs.
mos.
ds
Where was disease contracted, If not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL St. Patrick's Cemetery.
DATE OF BURIAL
Dec. 8. 1912
(Address)
Lowell Mars.
15 Filed ... DEc. 9, 1912. Edward for Robbery
REGISTRAR
16 DATE OF DEATH
(Month)
5
(Day)
1912.
(Year)
I HEREBY CERTIFY that I have investigated the 17 death of the deceased. The CAUSE OF DEATH* was as follows : accident (BONRR) (Run our ly Train )
10 NAME OF
FATHER
John Herrie.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Mass.
12 MAIDEN NAME
OF MOTHER
Mary E. Burns,
13 BIRTHPLACE
OF MOTHER
(State or country)
Maca.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. Frances J. Walker
In the
20 UNDERTAKER
GromHealey.
ADDRESS
79 Branch Of
9 BIRTHPLACE
(State or country)
Dracut, Mace.
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. Tbe 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 bome, 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 (tbe 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-
1
culosis of lungs, meninges, peritonaeum, etc., C'arcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles ; Whooping cough ; Chronic valvular heart disease; · Chronic interstitial nephritis, etc. Tbe contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease causing deatb), 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," "Haemorrbage," "Inanition," "Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as tbe cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for wbicb surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident ; Revolver wound of head-homicide ; Poisoned by carbolic acid - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the bead of "Contributory."
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. Deatbs 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
Sarah& Louder 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE East Chelow ford Sklass
St. :
Ward)
(City or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
1 PLACE OF DEATH
(No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
volete
WIDOWED,“
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
18.54%
...
(Year)
If LESS than
I day .......... hrs.
7 AGE
78 . 4
.... yrs.
or ......... min. ?
.mos.
ds.
-
$ 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)
Ireland
10 NAME OF
FATHER
Joseph learn
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Lance Graham
PARENTS
Ireland
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
James H. Bowden
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
....
(Month)
(Day)
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
.....
15 Filed Dic. 9 1913 Edward Y. Roffi bing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
HER.
(Day)
6th
1912 (Year)
17
I HEREBY CERTIFY that I attended deceased from
Nov.24, 1912 to
DEC. 6th
1912
......
.......
...
that I last saw her alive on
Die, 6th
1912
m.
and that death occurred, on the date stated above, at 4P
The CAUSE) OF DEATH* was as follows :
Intestinal ofstructure
(Duration).
... yrs.
.mos.
ds.
Contributory .. (SECONDARY)
.. (Duration) ....
yrs.
mos.
ds.
(Signed)
DER. 7.
1912 (Address).
Forwell.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR 'RECENT RESIDENTS).
At place
of death.
yrs.
mos.
ds.
State ...
.......... yrs.
In the
........... mos. ........
....
ds ...
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Edrow Ceunitary Des/ 9, 1912
20 UNDERTAKER
Satur a. Meinebeck 16Market. It.
165
Registered No.
79
(Month)
M.D.
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, Laborcr- 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," " All- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
APLACE OF DEATH Forth hele ford (No. Junge For Street ..............
St. :
,166/1 hale ford pass Ward) (City or town.) Tlf death occurred in a hospital or institution, give its NAME instead of street and number.]
Margaret Delaf
margaret Mica
......
Registered No.
80
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
steccale
4 COLOR OR RACE
-
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1.5 18,29
(Month)
(Day)
(Year)
7 AGE
If LESS than [ day ......... hrs.
....... yrs ..
24
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) ...
Wnie hilfe
9 BIRTHPLACE
(State or country)
Ireland
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Juland
12 MAIDEN NAME
OF MOTHER
Mau, MC Mahon
13 BIRTHPLACE
OF MOTHER
(State or country)
Diefand
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Theos argy MS Calm Daughter
(Address) Princeton Street, Inth Cheles ford
18 Filed JEc.12 , 1912 20abstand, Robbins ..............
REGISTRAR
10 DATE OF DEATH
December
9
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from Sac 4, 1912, to. ...... ...
1913
that I last saw her alive on ...
Slag, 9, 1
191.2 ...
and that death occurred, on the dato stated above, at ................
..... m.
The CAUSE OF DEATH* was as follows :
proflexy
.. (Duration)
.yrs.
...
mos.
ds.
.....
Contributory ..
arterio Schermer
......................................
(SECONDARY)
(Duration)
............ yrs.
mos.
ds.
(Signed)
Cassidy
M.D.
.....
Des. (0)
2 . 1912 (Address)2
24 Runels Ble
* 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.
ds.
......
In the
Where was disease contracted, if not at place of death ?...... Former or -
usual residence ...
19 PLACE OF BURIAL OR REMOVAL null I. Paturs) Century
DATE OF BURIAL
De 12 1912
20 UNDERTAKER
ADDRESS
1912
6 DATE OF BIRTH
Feb
...
'FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Trening Street fath Chelies ford
MARGIN RESERVED FOR BINDING
10 NAME OF
FATHER
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.ª 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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