USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 21
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Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to timo and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fevcr (the only definite synonynı is "Epidemic eerobro-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, ete., 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 symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," ete.), " Dropsy,""Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease ean 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 strect, or one supposed to be due to Alcoholism, etc.
4. Deaths under eircumstances 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. Heigh
St. :
Ward)
'FULL NAME Susie Belle Nobb
line
Herbert L. Robbins, Lucie B. Whitcomb.
Registered No. 85
PERSONAL AND STATISTICAL PARTICULARS
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford
3 SEX
4 COLOR OR RACE
7
6 DATE OF BIRTH
10
(Month)
(Day)
7 AGE
yrs.
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) ...
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
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
42
4 mos. 20
mos.
ds.
5 SINGLE,
MARRIED
Widowed
WIDOWED,
OR DIVORCED
(Write the word)
1870
(Year)
If LESS than
1 day ......... hrs.
.......... min. ?
9 BIRTHPLACE
(State or country)
No. andover
Mass.
10 NAME OF
FATHER
John N. Whitcon
11 BIRTHPLACE
OF FATHER
(State or country)
No. Andover Mars.
12 MAIDEN NAME
OF MOTHER
Alberca E Carlton
West Bedford.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(informant)
. N. W hetcoul (factor)
(Address)
Chelmsford, Mais
16 Filed Jan. 21912 Edward For Rottin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec
30
(Month)
(Day)
192.
(Year)
I HEREBY CERTIFY that I attended deceased from
time 21: 1912 to 201.23
1, 19 2
that I last saw het alive on
201.2-3
. 191 2
and that death occurred, on the date stated above, at ...
m.
The CAUSE OF DEATH* was as follows :
Multiple Carcinoma-
.(Duration)
4
yrs.
.mos.
ds.
Contributory.
(SECONDARY)
(Duration)
.. yrs.
mos.
ds.
(Signed)
Arthur d. Scaborca
1
M.D.
Jan. 1, 1913
Chilestown, mais.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
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
West Cemetery.
Littleton Mars
DATE OF BURIAL
Jan 2
1913
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford.
Cchusford. (City of town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
17
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. Tho question applies to each and every person, irrespective of age. For many occupations a single word or terni on the first line will bo sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, 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 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 samo disease. Examples: Cerebro-spinal fever (the only definite synonynı is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- coma, etc., of (name origin: "Cancer" is less definite; avoid use of " Tumor" for malignant neoplasins) ; 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," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Haemorrhago," " 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, 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 Commwealth of Massachusetts
Cheluces ford 172
1 PLACE OF DEATH
STANDARD CERTIFICATE OF DEATH
With Thelaw ford (No.
Pringles der
(City or town.)
[If death occurred In
a hospital or institution,
give its NAME instead
Stell Dove Vimegan
of street and number.]
St. :
Ward)
'FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Dingley der worth Chelios Mond Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR, RACE
$ SINGLE,
1ª DATE OF DEATH
Vingle
MARRIED,
WHOOWEB,
OR DIVORCED
(Year)
...
(Write the word)
(Month)
9
(Day)
1915
....
6 DATE OF BIRTH
17
I HEREBY CERTIFY that I attended deceased from
Jan
9
196
(Month)
(Year)
(Day)
.
191.
... , to
191
7 AGE
If LESS than
.....
I day .......... hrs.
191
that I last saw h
alive on.
........
and that death occurred, on the dato stated above, at.
m.
The CAUSE OF DEATH* was as follows :
-
yrs.
mos.
.. ds.
......... min. ?
8 OCCUPATION
(e) Trade, profession, or
particuler kind of work.
............
Stillbons Congenital atelectais
(b) General neture of industry,
business, or establishment in
which employed (or employer) ....
9 BIRTHPLACE
(State or country)
(Duration)
.... yrs.
.ds.
Forth Theluce ford
mos.
....
Contributory.
10 NAME OF
FATHER
toho Hennegan
(SECONDARY)
(Duration)
.......
... yrs.
......
mos.
... ds.
(Signed)
M.D.
11 BIRTHPLACE
Wieland
(Address) Wo Chelmsford
OF FATHER
(State or country)
Jau 9, 1913
* IA death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
12 MAIDEN NAME
OF MOTHER
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
Margaret M. Cali
PARENTS
At place
In the
Queland
of death ..
....... yrs. ............ mos.
... ds.
State ............ yrs.
............. mos.
.......
ds .............
13 BIRTHPLACE
Where was disease contracted,
if not at place of death ?.
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
mathes
Former or
usual residence.
(Informant)
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
(Address) Jungle air North Hollisterd
St. Tatu Counter Truy Jan 11 1915
important. See instructions on back of certificate.
16
20 UNDERTAKER
ADDRESS
N. B .- Every Item of information should be carefully supplicd. 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
....
0 Filed Jan. 11 1918 Edward . Robimy ......... REGISTRAR
..............................
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, peritoneum, 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 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 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.
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
(No
Crosby Place
2FULL NAME Rebecca Jane Sargent
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
Chas. H. Sargent
Registered No.
2
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
- Female
4 COLOR OR RACE
white
1 5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write tho word)
Widow
6 DATE OF BIRTH
March
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day ......... hrs.
77
yrs. 10
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)
10 NAME OF FATHER
PARENTS
Il BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Illro Chas B Cola
(Address) Chelmsford
15 Filed Jan. 10, 1913 Edward J. Robb.
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
Mov 26
. 1912, to.
Jau 9
., 1913
that I last saw h alive on
Jan 9,
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
aceite Lobar
Pneumon
oui (Duration)
.yrs.
.mos ..
ds.
Contributory
(SECONDARY) .
neuritis-Multiple (Duration)
Grout 4
.. yrs.
mos.
ds.
(Signed)
Antru J. Fcofarias
M.D.
Yang,
1913
(Address) Kunahans ford Jnade.
* 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
north Parish Com
Haverhile
DATE OF BURIAL
Jan 10, 193
20 UNDERTAKER
Walter Perhan
ADDRESS
Chefreford
(Day)
9
191 3.
.....
(Month)
(Year)
1835
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Saw
173 Thelmaford Ward) (City ortown.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. :
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 he sufficient, c. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive cngincer, Civil engineer, Stationary fircman, 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) Salcs- man, (U) Grocery ; (a) Forcman, (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- kcepers who receive a definite salary), may be entered as Hlouscwife, 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 timo 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 fcver (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) ; Mcasles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not he stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report more symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhago," " 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 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 duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dcad, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Cast Chelmsford
(No
Manning Place &
Ward)
William Manning.
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
East Chelmsford.
Registered No.
3
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jan,
16.
1913.
(Year)
0
(Month)
(Day)
18128.
17
I HEREBY CERTIFY that ) attended deceased from
Nov. 29
..... 1912 to.
Sau 16,, 1913
/1
.........
that I last saw h.Alanalive on
Man. 16,
1913
and that death occurred, on the date stated above, at / P.
.............. , .m. The CAUSE OF DEATH* was as follows : Fracture ofleft few of hip join
nov 29-12 to Jan. 16, 1973. (Duration) .... mos. ds. ......
....
Contributory ..
(SECONDARY)
(Duration) .yrs.
mos.
ds.
(Signed)
Arthur J. Scolonia
M.D.
Law.17, 1913 (Address).
......
Olulineford, mais,
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
.yrs
mos.
ds.
State ....
......... yrs.
. ..........
In the
mos.
ds
..............
Where was disease contracted, If not at place of death ?.
Former or usual residence .....
19 PLACE OF BURIAL OR REMOVAL Fox Hill Cemetery. Billerica, Masa.
DATE OF BURIAL
Jan, 19 1918.
ADDRESS
20 UNDERTAKER
Grom Healey 79 Branch Of
174 East Chelmsford. (City owtowne) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
Nale. White
5 SINGLE,
Widowed
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Oct 29.
(Month)
(Day)
(Year)
If LESS than
7 AGE
I day, ........ hrs.
809
mos
mos
18 ds.
.... yrs.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Manufacturer
(b) General nature of industry,
Retired
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Billerica Mars.
10 NAME OF
FATHER
Theophilus Manning
11 BIRTHPLACE
OF FATHER
(State or country)
Billerica, Mars.
12 MAIDEN NAME
OF MOTHER
Polly Patten
PARENTS
Billerica, Mack
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Grastuas An Bartlett
(Address) E Chelmsford Marks
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
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
.........
16
Filed _.
Jan.19, 1913 Edward & Robbins
REGISTRAR
......
....
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 iaborer, 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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