USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 20
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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, 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford
(No.
Billerica
St.
Ward)
Edwin E. Hall
Billerica & Chelmsford
Registered No.
81
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH 120 10
(Month)
(Day)
1912>
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
accidental Poisoning by Gesalines zelf administered (Duration) ... yrs.
Contributory
(SECONDARY)
.(Duration)
.. yrs.
mos. ds.
IV. Mais
M.D.
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).
In the
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
Dovev.
N.H
DATE OF BURIAL
Klec. 14, 1912
16 Filed Decr 14, 1913 Edward &. Robbins
REGISTRAR
167 Chelmsford (City or town.)
[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
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Ufrite
5 SINGLE,
Single
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Heb
/3
(Month)
(Day)
7 AGE
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Chelmsford Mars
10 NAME OF
FATHER
Cutis 2. Holt.
11 BIRTHPLACE
OF FATHER
(State or eonntry)
Manchester N.H
12 MAIDEN NAME
OF MOTHER
Georgia Floss
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
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
2
.. yrs.
9
mos.
28
.ds.
or ........ min. ?
1910
(Year)
If LESS than
| day, ........ hrs.
Newburyport Mars
(Informant)
C.I. Hold, Clickneford. Mais
20 UNDERTAKER
Walter Fecham
ADDRESS
Chelinefund. Mars
mos.
ds.
(Signed)
Fre 12, 1912 (Address).
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, 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. 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 head 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. 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.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 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 Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
.(No
-Chelmsford Ph.
St. :
Ward)
2FULL NAME
Eleristina ashworth
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford
Meses, James achword
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Hemale
-
6 DATE OF BIRTH
non
(Month)
22
(Day)
1846
(Year)
7 AGE
If LESS than
1 day, ........ hrs.
66
yrs.
0
.... mos.
21
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)
Paisley Scotland
IO NAME OF
FATHER
Robert Michel
PARENTS
11 BIRTHPLACE OF FATHER (State or country) (5) Parsley Scotland
12 MAIDEN NAME
OF MOTHER
Elizabetty Thomson
13 BIRTHPLACE OF MOTHER (State or country) Paisley Scotland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Margaret achword
(Address)
Chelmatural
16
Filed DEc. 14. 1912 (devard) Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
December
(Month)
Friday
13
(Day)
19121.
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Oct. 22
. 1912 to
Fc 12- 192
that I last saw her alive on.
Dic 12
1912
and that death occurred, on the date stated above, at 7-301m.
The CAUSE OF DEATH* was as follows :
(Duration)
... yrs.
mos.
ds.
Contributory ..
Myocardial DEgeneration and
Uterne ist, rien timmer
Duration)
.. yrs.
mos.
ds.
(Signed)
M.D.
DE.c.15, 1912 (Address).
Cheminford maso.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
.. yrs.
In the
mos.
ds.
State.
....... yrs.
.mos.
ds.
....
Where was disease contracted,
If not at place of death ?.
Former or usual residence ............... ....
19 PLACE OF BURIAL OR REMOVAL Horefactions Cours Chelmsford
DATE OF BURIAL
De15 1912
20 UNDERTAKER
Walter Pertan
ADDRESS
Chelunfork
Chelmsford 168 (City or xown.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
82
4 COLOR OR RACE
white
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Widow
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 tho 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 oxamples: (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 Hlouse- keepers who receive a definite salary), may be entered as Ilousewife, 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 discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," " Convulsions," " Debility " ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACÉ OF DEATH Chelunsford Maso .(No Chelmsford Street St.
John Conaton
FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelives ford Street Cheli ford
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
Die.
25
1912
.
(Month)
(Day)
(Year)
6 DATE OF BIRTH
(Month)
(Day)
18.60
(Year)
7 AGE
If LESS than [ day .......... hrs.
052
.. 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) ...
tarnung
9 BIRTHPLACE
(State or country)
Queland
Contributory ... (SECONDARY)
.. . (Duration)
.............. yrs.,
mos.
ds.
(Signed)
Anhn G. Scobona
.....
M.D.
Dec. 20 1012 (Address)
Chilis fordi max,
* 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 Ou St. Fatura Century
DATE OF BURIAL
See 2/ 19/2
(Address)
Chilesford Street
16
Filed DEC. 27, 1012 Edward I Rostlin
REGISTRAR
Chrome gastritis
Chrome niephrets
(Duration)
yrs.
.mos.
ds.
10 NAME OF
FATHER
Michael Conation
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Uneland
12 MAIDEN NAME
OF MOTHER
May Joy &
18 BIRTHPLACE
OF MOTHER
(State or country)
Ruland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Catherine Comaton hal
Cheluns ford Maso
169
(Oty or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
...........
„Ward)
.
Registered No.
83
3 SEX Male Ato
4 COLOR OR RACE
1 5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Maised
17
I HEREBY CERTIFY that I attended deceased from
191.
.... , to
Dec 24 92
that I last saw havialive on
...........
......... , 191.
3
and that death occurred, on the date stated above, at ...............
.m.
The CAUSE OF DEATH* was as follows :
...
......... ......
20 UNDERTAKER
ADDRESS 324 Mayset Of
-
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 applics 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 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 tho 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.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
'FULL NAME 3 SEX temata 6 DATE OF BIRTH 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 ......
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Martha Douglas
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
Film, LDouglas
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Die
28
(Month)
(Day)
1912
(Year)
17
I HEREBY CERTIFY that I attended deceased from
nov.
.191/. to
Die 27
1912
that I last saw h Ca alive on.
DEC. 27,, 1912
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Ischaemic Schon
.
(Duration)
.. mos.
ds.
Contributory (SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
M.D.
* If death followed injury or violence thecertificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, CTRANSIENTS, OR RECENT RESIDENTS).
In the
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
Pine Ridge Com, Cheleufen).
DATE OF BURIAL
DEC 30
1912
(Informant)
(Address) Chelmituns
16 Filed Dec. 30, 1912 Edward J. Rowling
REGISTRAR
170 Chelmsford
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.}
4 COLOR OR RACE
white
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Married
20
(Month)
(Day)
(Year)
If LESS than 1 day, . hrs.
47
.. yrs.
2
mos.
3
d3.
or ........ min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
itt home
(b) General nature of industry, business, or establishment in which employed (or employer).
} BIRTHPLACE
(State or country)
Maraton Nova Scotia
10 NAME OF
FATHER
alfred Wilson
II BIRTHPLACE OF FATHER (State or country) Marstours, N.S
12 MAIDEN NAME
OF MOTHER
proline Macnutt
13 BIRTHPLACE
OF MOTHER
(State or country)
Maestros N.8
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(No. Bartlett Sh
St. :
Registered No.
84
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
2
or more
.yrs.
., 1912
Arthur & Scotina
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, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necossary 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 wlien necded. 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 Ilousewife, Housework, or At home, and children, not gain- fully employcd, 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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