USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 23
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).
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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 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.
--
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH no. Chelmsford ( No Middlesex St.
Mary Coffy
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Middlecey H., No. Chelmehrd
Registered No.
8
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jan.
(Month)
31
(Day)
1913 (Year)
I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
Myocarditis
(Duration) ..... .. yrs. ... .. moș. ds.
Contributory (SECONDARY)
(Duration) .... yrs. M. Meigo .mos. ds. M.D.
(Signed) FW. 1
1913 (Address).
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.
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 Trys Hell Kemetry
RATE OF BURIAL Firb 3. 1913
20 UNDERTAKER
ADDRESS
15 Filed Feb 1, 1913 Edward . Robbing
REGISTRAR
179 he Chelnfred (City or town.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
3 SEX 4 COLOR OR RACE male While
6 DATE OF BIRTH
18007 (Year)
(Monthı) (Day)
7 AGE
If LESS than 1 day, ......... hrs.
.yrs.
mos. ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work.
Co Home
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE (State or country) Lyland.
10 NAME OF FATHER
Riffy
PARENTS
11 BIRTHPLACE OF FATHER (State or country) allang
12 MAIDEN NAME OF MOTHER
Chuknown
18 BIRTHPLACE OF MOTHER (State or country )
auland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address) Growth cheland mass
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
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the ft)
Single
It Downall oue Cound mess
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 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, peritonaeum, etc., C'arcinoma, Sar- coma, ctc., 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.
3 SEX Female 7 AGE 8 OCCUPATION 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 North Chelmsford
MASS
St. :
.............. .Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
'FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Caroline H. Crooker. Orin C. Luke
Registered No.
9
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
February
2.
1913
.....
(Month)
(Day)
(Year)
6 DATE OF BIRTH
October
(Month)
(Day)
(Year)
If LESS than
Į day .......... hrs.
43
3'
.. mos.
7
„ds.
... yrs.
At
Home
(b) General nature of industry, business, or establishment in which employed (or employer) .........
9 BIRTHPLACE
(State or country)
Stockton
Maine
10 NAME OF
FATHER
Edward Crocker
13 BIRTHPLACE
OF FATHER
(State or country)
Stockton
Maine
12 MAIDEN NAME
OF MOTHER
Mary
Lamplur
13 BIRTHPLACE
OF MOTHER
(State or country)
Bucksport Maine
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Orin C.
Luke
(Address)
No. Chelmsford Mass
Filed tel. 2, 1913 Edward &. Robbin
......................
REGISTRAR
...
17
I HEREBY CERTIFY that I attended deceased from
november
, 1912 to
July 2
191 3
that I last saw hralive on
1913
and that death occurred, on the dato stated above, at.
6 a.m.
The CAUSE OF DEATH* was as follows :
.
Pulmonary tuberculosis
(Duration)
3
yrs.
mos. ...
ds.
Contributory ...
(SECONDARY)
(Duration)
yrs.
....
mos.
.ds.
(Signed)
7 E Jamey
M.D.
July 3, 1913 (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 Stockton man
DATE OF BURIAL
Feb 3, 1913
30 UNDERTAKER
ADDRESS
6. m. young 33 Prescott
MARGIN RESERVED FOR BINDING
180
....... ....
(City or town.)
Caroline H. Luke
4 COLOR OR RACE
White
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) Married
24.
I869
or ......... min. ?
(a) Trade, profession, or
particular kind of work
....
........
.......
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.
-
1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No .... Town Har
St. :
181 Chelmsford (City or town.) Ward) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
2FULL NAME Lenge Edgar Emerson [If married or divorced woman or widow give maiden name, also name of husband.] aRESIDENCE Chelmsford
Registered No.
10
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
191 3 .
(Year)
17 I HEREBY CERTIFY that I attended deceased from , 1913, to tab. 4 1913.
₡
If LESS than
[ day, ..
...... hrs.
that I last saw h Alizalive on
Jeb, 4, 1913.
and that death occurred, on the dato stated above, at ....
.m.
The CAUSE OF DEATH* was as follows :
Pulmonary Tuberculosis
mos.
ds.
Serial monitor perhaps years -
Contributory ...
(SECONDARY)
.... (Duration)
.yrs.
mos.
ds.
(Signed)
Anh & Tortona
M.D.
Meb. 6, 1913 (Address) Chelmsford, marv.
* If death followed injury or violence the certificate of death must be made ont 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 ..
12 PLACE OF BURIAL OR REMOVAL
-
Horefattura Com.
DATE OF BURIAL
Hleb ?
. 1993
20 UNDERTAKER
Malta Perham
ADDRESS
Chelmsford
-
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
' PLACE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
quale
4 COLOR OR RACE
white
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
2
1537
married
(Month)
(Day)
(Year)
7 AGE
ds.
or ....... min. ?
75
2
... yrs.
mos.
3
8 OCCUPATION
(a)' Trade, profession, or
Inviate
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Chelmsford
10 NAME OF
FATHER
Franklin Emerson
11 BIRTHPLACE
OF FATHER
(State or country)
Chelmsford
12 MAIDEN NAME
OF MOTHER
Rebecca Kittridge
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
Chelmsford
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mro Seo. S. Emerson
(Address)
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.
16
Filed
Feb. 5 .1013 Edward S. Robbins
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
....
REGISTRAR
... (Duration)
.. yrs.
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 laborcr, 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 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 ; 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 neoplasmns) ; Measles ; Whooping cough ; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or interenrrent) 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 ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," " 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 strcet, 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 Na + Chefmyfact. (No.
St. : Ward)
(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 Wart Chelmsford- Mars-
1 Schman Curquest-Loubière
Registered No.
11
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
12
193
....
(Month)
(Day)
(Year)
6 DATE OF BIRTH
Moramper- 11
-1849
.........
1
(Month)
(Day)
(Year)
7 AGE
If LESS than I day, .... hrs.
63
...... yrs ...
3
.mos.
1
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)
(Duration)
.. yrs. ...
mos. .. ds.
Contributory ..
(SECONDARY)
Duration)
JEVarney
.yrs.
mos.
.ds.
(Signed)
M.D.
July 13, 1913 (Addres
............
* 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 Ir Cheimsint ineters.
DATE OF BURIAL
Fab. 14, 19/2
.............
(Address)
Spent, Chefan vad. Mars-
15 Filed Feb. 12, 191 / Edward ). Kobling
REGISTRAR 12.65ª
1 I HEREBY CERTIFY that i attended deceased from
. 1912 to
July 12 193
......
that I last saw her alive on ..
1913
and that death occurred, on the date stated above, at Sam.
The CAUSE OF DEATH* was as follows :
Cancer y levis státech
10 NAME OF
FATHER
John Cohenzona.
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
r
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
august Larvina
182 Chefmlad.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
PARENTS
...
....
20 UNDERTAKER L
David Le Greig
ADDRESS
Westerde 9/1/a 22
3 SEX
4 COLOR OR RACE
Finala. Hohite
5 SINGLE
Married.
WIDOWED,
OR-DIVORCED
(Write the word)
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 Ilousewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should bo taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has beeu 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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