USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 22
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.
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 Jar Chelmsford (No: Vaste Lechelmsford St. Ward)
2 FULL NAME Stewart m MC Connell
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
1 MEDICAL CERTIFICATE OF DEATH
3 SEX
nale
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
& DATE OF BIRTH
Lled (Month)
20
19/217
(Day)
(Year)
' AGE
If LESS than I day, ....... hrs.
yrs. .mos.
29
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
9 BIRTHPLACE (State or country) Tehelmeland Mass
10 NAME OF FATHER Howard Me Camell
11 BIRTHPLACE
OF FATHER
(State omcountry)
Naw
Brunswick
12 MAIDEN NAME OF MOTHER
Park
1% BIRTHPLACE G.OF MOTHER 1 7(State or countr
LEmma. - Hille
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Haward Meleannel
(Address)
16 Filed Jan 20 1913 Edward S. Potting
REGISTRAR
16 DATE OF DEATH
lan
anway
1913
....
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
Dec 20, 1912
to
Suy 18
., 194.3
that I last saw h alive on
July 18
. 1912
.........
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Congenital Debility
(Duration) Az becch
Contributory.
(SECONDARY)
... (Duration)
... yrs.
mos.
ds.
(Signed)
JE Varney
M.D
may 19, 1913 (Address).
* If death followed injury or violenee the eertifieate 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 ?. 1 .... Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
Recuer Tide
DATE OF BURIAL
Lam 20 193
ADDRESS
~ UNDERTAKER
Mo. Wemback 16 market
175
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
X
.mos.
ds.
PARENTS
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 lias 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: Cercbro-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-
1
-
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 , 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.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH levelnatural. (No
St. :
Ward)
[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
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Januar
(Month)
(Day)
...... (Year)
17
I HEREBY CERTIFY that I attended deceased from
191
to
1913
If LESS than
I day,
... hrs.
that I last saw hm alive on.
1913
and that death occurred, on the date stated above, at 5:30 Pm.
The CAUSE OF DEATH* was as follows :
auquea Pectoris
.(Duration)
.... yrs.
... mos.
ds.
Contributory.
organe disease of heart. no
(SECONDARY)
Glory veaces
(Duretion)
... yrs.
mos. ds.
(Signed)
JE Varney
M.D.
ty 28
, 1913 (Addre
H. Chollos fest,
* 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
mos.
ds.
State.
.yrs.
mos.
ds
Where was disease contracted, If not at place of death ?
Former or usual residence ..
12 PLACE OF BURJAL OR REMOVAL
DATE OF BURIAL
(Informant).
(Address)
Filed am 30, 1913 Edward ), Robbing
REGISTRAR
Vidirica
6 DATE OF BIRTH
1844
-
(Month)
(Day)
(Year)
7 AGE
69
yrs.
mos.
2 4s.
or ........ min. ?
8 OCCUPATION
(a) Trede, profession, or perticuler kind of work.
(b) Generel neture of industry, business, or establishment in which employed (or employer) ..
· BIRTHPLACE
(State or country)
10 NAME OF
Charles learnell
11 BIRTHPLACE OF FATHER (State or country)
PARENTS
12 MAIDEN NAME OF MOTHER i wass.
1ª BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
191 3
20 UNDERTAKER Webech &
ADDRESS uvedl
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
176
(City or town.)
Charles de Carnell
Registered No.
3 SEX
Male White
4 COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
191 3
In the
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) Salcs- 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 cercbro-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, ctc , C'arcinoma, Sar- coma, etc., of. (name 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 in- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " All- acmia " (mcrely 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, 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 onc 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 Commwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford (No. aiuleton
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No. 6
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
7.05
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Single
16 DATE OF DEATH
lan
......
(Month)
(Day)
(Year)
6 DATE OF BIRTH
ihril
14
1862
17
/ (Month)
(Day)
(Year)
7 AGE
If LESS than I day, ........ hrs.
20
9 mos.
15
.yrs. ...
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).
Hemorrhagic Supura
Pulmonary Infarction
-
... yrs.
mos.
ds.
.... (Duration)
......
Contributory
(SECONDARY)
(Duration) .
.......
.yrs.
mos.
ds.
Authmy. Pertina
-
M.D.
(Signed)
Jan, 31
, 1913 (Addres).
Chimstorel mass.
* 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 ....
1 PLACE OF BURIAL OR REMOVAL Edson lem gowell Mann.
DATE OF BURIAL
Act-1
1913
......
(Address)
Chelmsford,
15
Filed ....
Feb. 1. 1913 Edward Q, Rolling
REGISTRAR
Cehelní
177
...
2FULL NAME.
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
L'ansche
MARGIN RESERVED FOR BINDING
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Bergen.
Norway
12 MAIDEN NAME
OF MOTHER
. c Neilsen
13 BIRTHPLACE
OF MOTHER
(State or country)
Bogen Noway
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Criminta Paasche
20 UNDERTAKER
ADDRESS
Chelmsford,
29 93
I HEREBY CERTIFY that |
attended deceased from
191.
.... , to
Jan. 24
.... 1913
that I last saw her alive on.
.... .
Han 28
1913
and that death occurred, on the dato stated above, at 3 a. m.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
ouvert, Mords.
10 NAME OF
FATHER
Alexander B. Taasche
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, 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 Ilouse- 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 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, peritonaeum, etc., Carcinoma, Sar- eoma, 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: Mcasles (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," " 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.
The Commonwealth of Massachusetts
178
... (City or town.)
[If death occurred In a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
w
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Rughy
6 DATE OF BIRTH
/(Month)
(Day)
1883 17 (Year)
7 AGE
If LESS than ! day .......... hrs.
27 yrs. 9 mos. 28 de
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
England
PARENTS
13 BIRTHPLACE
OF FATHER
(State or country)
Un kumar
12 MAIDEN NAME
OF MOTHER
11
13 BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Frank x. publerle
(Address)
15 Filed. Jausd/ 1913 Eduard queles ............
REGISTRAR
1ª DATE OF DEATH
Jan. 29
(Month)
(Day)
1913
(Year)
I HEREBY CERTIFY that I attended deceased from
.....
191 .
....... , to
191
........
that I last saw h ............. alive on
191
........
and that death occurred, on the dato stated above, at ....
................ m.
The CAUSE OF DEATH* was as follows :
Electrical such
Menmably accidental
.. (Duration) ................ yrs. ................ 08. ................ ds.
Contributory .. (SECONDARY)
4 ... (Duration) .
.......... yrs.
....... mos.7 ............
ds.
(Signed)
.....
Frank hans Rile
M.D.
San 29. 1913 (Address).
aynı Mexx !!
...........
* If death followed injury or violence the certificate out by the Medical Examiner.
the cermicate of death must xavier
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death
.... yrs.
.. mos. ............. da.
State ............ yrs. ............ mos. ..
............ ds .............
Where was disease contracted, If not at place of death ?. .... Former or usual residence.
12 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL Hast Celuastral Jau 3/1913
(ADDRESS
20 UNDERTAKER HalleDirham Plus
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
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Suasil Chapman
St. ;..
Ward)
FULL NAME
[If marricd or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
1
......
..............
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 singlo 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) 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- 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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