USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 24
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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 : Mcasles (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.
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 Mr. Chelmsford( (No. Groton Road
-St. : Ward)
183
(City or town.)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
12
3 SEX
female
14 COLOR OR RACE
white
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
single
· DATE OF BIRTH
Feb
19
1893
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day, ....... hrs.
19
.yrs.
11 mos
mos. 27
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ..
took-keeper
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
no. Chelmsford
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
annie Rearne.
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(informant)
William Welch
(Address)
No. Chelivefor
ford
16 Filed 216. 19 1913 Edward Spotting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
(Month)
17
1913
....
17
I HEREBY CERTIFY that I attended deceased from
July 16 , 1913 to
1913
that I last saw her alive on.
July 17
1913
.... .
and that death occurred, on the date stated above, at 7 9.m.
The CAUSE OF DEATH* was as follows :
aceite intestinal obstruction
(Duration)
2 4 hours.
... yrs. ....
................ mos.
ds.
Contributory
(SECONDARY)
(Duration)
.......
.... yrs.
mos.
ds.
(Signed)
JE Varney
M.D.
..... 1913 (A)
(Address) H. Chekasfert
* 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 ...
............. yfs.
In the
mos.
ds ...
.........
....
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
Riverside Centro Chelme.
DATE OF BURIAL
Jeb. 19.
1913
20 UNDERTAKER
S.A. Weinbeck
ADDRESS
16 Market St.
(Day)
(Year)
Viola Luda Welch 2 FULL NAME [If married or divorced woman or widow/ give maiden name, also name of husband.] @RESIDENCE No. Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
MARGIN RESERVED FOR BINDING
10 NAME OF
FATHER
William Welch
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 needcd. 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 Ilouse- 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 ncoplasms) ; 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
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
I PLACE OF DEATH? Chelmsford (No. Cutre . F
St. :
1840 Chelmsford (City or ffown.) Ward) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
‘FULL NAME Frances Ladelaide adams
[If married or divorced woman or widow give maiden name, also nang of husband.] @RESIDENCE Chaletatd.
James Udans
Registered No.
13
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
7
4 COLOR OR RACE
20
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
6 DATE OF BIRTH
let.
4
(Montlı)
(Day)
1841
(Year)
7 AGE
If LESS than
I day, ........
hrs.
71 yrs.
yrs.
4
„mos ..
19
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Nurse
.
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Chelmsford
PARENTS
12 MAIDEN NAME OF MOTHER Elizabeth Emerson
13 BIRTHPLACE
OF MOTHER
(State or country)
chelmsford
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(informant)
Mottsadou
(Address)
15
Filed
Feb. 28 1913 Edward J. Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
February
23rd
(Month)/
(Day)
191.3.
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Feb. 13th
1918, to
Feb. 23rd
1913,
that I last saw her alive on
Feb. 23rd
-
191.3 ....
and that death occurred, on the dato stated above, at 4.15 m.
The CAUSE OF DEATH* was as follows :
Freumonia)
(Duration)
.. yrs.
.mos.
10 ds.
Contributory. (SECONDARY)
.(Duration) .
.... yrs.
.mos.
.ds.
(Signed)
masa Stoward
M.D.
Feb. 24
191.3.(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.
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 torsdag
DATE OF BURIAL
Feb. 26
93
DO UNDERTAKER
Walter Lechan
ADDRESS
Chelmsford
MARGIN RESERVED FOR BINDING
10 NAME OF
FATHER
Elijalo Richardson
11 BIRTHPLACE OF FATHER (State or country) Chelmsford
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 tho 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 accopted 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 neoplasins) ; 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," "Senilo," 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
Cast Chelmsford
Trancio . Mc Grath
helmaford Maso Registered No.
PERSONAL AND STATISTICAL PARTICULARS
Vingue
-
(Year)
If LESS than l day ......... hrs.
or ........ min. ?
10 NAME OF Franck Ma Grath
11 BIRTHPLACE OF FATHER (State or country) Forvall Mass.
gathering Mc Gillian
13 BIRTHPLACE OF MOTHER State or country Forall Mage:
14 THE ABOVE IS TRUE TOTHE BEST OF MY KNOWLEDGE
Filed. Fuet. 25 3 Edward & Rolf
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
/ (Day)
2H
195
(Year)
17
1 HEREBY CERTIFY that, I attended deceased from Feb 23, 1913 to b 24 1915 ... that I last saw her alive on Tyle 23, 193 and that death occurred, on the date stated above, at 9 am. The CAUSE OF DEATH* was as follows : Ententes
7 .... (Duration)
.yrs.
.. mos.
ds.
Contributory.
(SECONDARY)
· € ... (Duration)
. mos. ds.
(Signed)
193 (Address) Les
* 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 /
( DATE) OF BURIAL
tuv-25 1913
East Chelmsford Those IN Sarah (Address)
20 UNDERTAKER
- ADDRESS foruvres
1 PLACE OF DEATH 2 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE East 3 SEX 4 COLOR OR RACE/ Make Altrita 5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the word) 6 DATE OF BIRTH (Month) (Day) 7 AGE 5 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) 12 MAIDEN NAME OF MOTHER PARENTS (Informant) important. See instructions on back of certificate. 15 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 yrs. mos. 15 ds.
185
(City or town.)
St. $
„.Ward)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
14
M.D.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preciso 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 ago. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Arehiteet, 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 thereforo an additional line is provided for the latter statement ; it should be used ouly 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 statoment. Never return " Laborer," "Foreman," " Manager,""Dealer," etc., without moro precise specification, as Day laborer, Farm laborer, Laborer -- Coal mine, etc. Women at homo, who are engaged in the duties of tho household only (not paid Ilouse- keepers who receive a definite salary), may be cntored as Housewife, Housework, or At home, and children, not gain- fully employcd, as At school or At home. Care should bo taken to roport 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 tho 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 malignaut neoplasms) ; Measles; Whooping cough; Chronie valvular heart disease; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (meroly symptomatic), " Atrophy," " Collapsc," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Hcart failuro," "Haemorrhagc," " Inanition," " Marasmus," "Old age," "Shock," " Uraemia," "Weakness," etc., when a definito disease can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL scptieaemia," " PUERPERAL peritonitis," ctc. Stato 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 bo 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.
3 SEX 7 AGE 8 OCCUPATION 9 BIRTHPLACE (State or country) PARENTS (Informent) important. See instructions on back of certificate. (Address) 15 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 (a) Trede, profession, or particular kind of work
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH, North Ghelmfun Andeller
Martha a
asivembre
Registered No.
15
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Dect - 20
(Month)
(Day)
..
(Year)
If LESS than
I day, ....... hrs.
32 yrs. 4 mos 10 ds.
or ....... min. ?
mill als.
(b) Generel nature of industry, business, or establishment in which employed (or employer).
Canada
10 NAME OF
FATHER
Pierre Essiembre
11 BIRTHPLACE OF FATHER (State or country)
Canada
12 MAIDEN NAME OF MOTHER Damage Quelle
13 BIRTHPLACE OF MOTHER (State or country)
Canada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Filed Dans, 3, . 1913 Edmond ), Rotting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Mach
2
1919
(Month)
(Day)
(Year)
1 HEREBY CERTIFY that I attended deceased from Feb 15, 19/3, to March 2, 1913 that I last saw hon alive on March 2, 19/9 and that death occurred, on the date stated above, at 46m. The CAUSE OF DEATH* was as follows :
Luft Rheumatic Fever
.(Duration) ....... ... yrs.
mos.
QU ds.
Contributory.
Heart aliis
(SECONDARY)
(Duration)
.yrs.
mos. ds.
(Signed)
James & Halvan
M.D.
Mar 2, 19% (Address)
dochalfred
* 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 RÉCENT RESIDENTS).
LẮt place
of death
... yrs.
.. mos.
ds.
State
.. yrs.
In the
mos.
ds
Where was disease contracted, If not at place of death ?
Former or usual residence.
/19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Mach 41913
20 UNDERTAKER
ADDRESS
7/38
ArArchambault mennoch
186
(City or town.)
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.1 @RESIDENCE
181
cease
...............
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 entercd 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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