USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 25
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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.
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 Chelmsford (No. Boston Rd.
St. :
Ward)
Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
Julia Elizabeth Warren FULL NAME
Varreu
[If married or divorced woman or widow mangan divinity Harrer give maiden name, also name of husband .. @RESIDENCE Chelmsford
Registered No.
16
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
16 DATE OF DEATH
mch.
1913
(Month)
(Day)
(Year)
6 DATE OF BIRTH
March
(Month)
28
1830
(Year)
7 AGE
If LESS than I day, ........ hrs.
52
.yrs.
11
mos.
3
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)
Cefclousfund
Les
10 NAME OF FATHER
Joseph Manning
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Chelmsford.
12 MAIDEN NAME OF MOTHER Julia M. Parker
| 13 BIRTHPLACE OF MOTHER (State or country)
Chebrefund
14 THE ABOVE ISITRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Sozinha Ef. Warren
(Address)
15 File mar, 5, 1913 Edward J. Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
Jan 1art. 1913, to.
Mich. 3ml
1913.
that I last saw her alive on.
Mich. 3td
1913
and that death occurred, on the dato stated above, at/a.m.
The CAUSE OF DEATH* was as follows :
Myocarditis ,
.. (Duration)
yrs.
.. mos.
ds.
Contributory ..
Senile
(SECONDARY)
(Duration) ... yrs. mos. ds.
(Signed)
amara toward
M.D.
Chelmsford. 11ax.
Mich, 4, 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 tirefactures Cem.
DATE OF BURIAL
Mar 5 1913
20 UNDERTAKER
Walter Perlang
ADDRESS
Checkrefund
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
:
:
L 7.
(Day)
18% Chehvisford. (City/or town.)
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative hicalthfulness 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, Architeet, Loco- motive enginecr, 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 Ilousc- 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 fevcr (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-
eulosis 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 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 dcad, 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
Chelmsford
.. (No
Prins Hill Road
St. :
188 Cheletech ....
(Citybr town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2FULL NAME aques Victoria Hullanders
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford Mass
Registered No.
17
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
7,
4 COLOR OR RACE
W
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
8 DATE OF BIRTH
Sept.
(Month)
(Day)
1/3
(Year)
7 AGE
If LESS than
1 day,
hrs.
mos.
11 ds.
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)
Caliceford
(Duration)
.... yrs.
mos.
1 dag.
Contributory
Scarlet Fever
(SECONDARY)
(Duration) .
.yrs.
mos.
3
ds.
(Signed)
ON. Wells
M.D.
mar. 7. 1913 (Address)
Westford, 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.
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
191
Ferie Redge Chulangues Mar. 8
3
.......
20 UNDERTAKER
Walts Perham
ADDRESS
REGISTRAR
16 DATE OF DEATH
March
7
(Month)
(Day)
1913
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Mar.5
191 3 , to
Man. 7
., 1913.
that I last saw he alive on Mar. 6
, 1913.
and that death occurred, on the date stated above, at 320 Am.
The CAUSE OF DEATH* was as follows :
Cerebral Embolisan Dur.3 hours
Endocarditis
10 NAME OF
FATHER
Louis 7 Hulslandu
Louis
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Franklin Mar.
12 MAIDEN NAME
OF MOTHER
Sauale Morrison
13 BIRTHPLACE
OF MOTHER
(State or country)
Victoriales Cape Breton
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Louis 7: Huelandu
P
(Address)
16 Filed Mar. 8. 1913 Edward J. Robban
Ward)
MARGIN RESERVED FOR BINDING
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 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, otc. 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 discases 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 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 Commmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford
(No ...
Boston Rd
St. :
Ward)
Registered No. 18
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
white
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Married
6 DATE OF BIRTH
March
(Month)
13
1838
(Day)
(Year)
7 AGE
75
0
yrs.
mos.
2
ds.
If LESS than
1 day, ........ hrs.
or ........ min. ?
8 OCCUPATION
Retired Haval Oficer U.S.M.
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Brooklyn 7.4.
10 NAME OF
FATHER
alfred Greenleaf
PARENTS
11 BIRTHPLACE OF FATHER (State or country) n'est Newbury, Mar.
12 MAIDEN NAME OF MOTHER Lucy & Hield
13 BIRTHPLACE
OF MOTHER
(State or country)
Salem, Mark
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
My CH Bruleat
(Address) Chelmatras 007/
16
File Mar. 15, 1913 Edward &. Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
March 15"
191.3
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from Than,5, 1913, to Mon 15 193 that I last saw his alive on aday 13 191.
and that death occurred, on the dato stated above, at. m. The CAUSE OF DEATH* was as follows :
(Duration)
.. yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration)
........ yrs.
.mos.
.ds.
(Signed)
M.D.
Man 16, 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.
In the
ds.
State ...
yrs.
mos.
ds ..
....
Where was disease contracted, If not at place of death ?.
Former or usual residence. ....
1º PLACE OF BURIAL OR REMOVAL
Brooklyn H.k.
DATE OF BURIAL
March 19, 1913
20 UNDERTAKER Matar Perfum.
ADDRESS
Chelmsford
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
Charles Flow Greenleaf 2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
189 Chelmsford (City of town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
MARGIN RESERVED FOR BINDING
(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, 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 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-
eulosis 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; 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 " (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 Ahah man (No)
Forth Chelunsford S
St. ;... ............. Ward)
Brady
friffen N Ready John . Grade
Registered No.
19
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
$ SEK
Veryali Mate
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
redners
25 1886
(Month)
(Day)
(Year)
7 AGE
If LESS than
{ day, ......... hrs.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ....
(b) General nature of industry.
business, or establishment in
which employed (or employer) ....
at Home
9 BIRTHPLACE
(State or country)
16 NAME OF
FATHER
Jatues Ready
PARENTS
1) BIRTHPLACE
OF FATHER
(State or country)
Wieland
12 MAIDEN NAME
OF MOTHER
18 BIRTHPLACE
OF MOTHER
(State or country)
Vueloud
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Daniel C.
Teade
(Address) INFightman Street
Filed Mar. 25, 1915 Ederized OraFort Binny
REGISTRAR
-
17
I HEREBY CERTIFY that I attended deceased from
august.
1912
to
Mich 23
1913
that I last saw her alive on.
mel 22 , 193
and that death occurred, on the date stated above, at 2 9 m.
The CAUSE OF DEATH* was as follows;
......
.(Duration) ....
2
.............. yrs.
................ mos.
ds.
Contributory ..
(SECONDARY)
(Duration)
............ y.s.
mos.
ds.
................
(Signed)
JElamy
..... 191 3 (Address).
H. Chelsea).
M.D.
.................
....
* 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
ds ...
of death.
.... yrs. ...
... mos.
da.
State ................ ............ mos.
în the
..........
....
Where was disease contracted,
if not at place of death ?...
......
..... Former or usual residence.
" PLACE OF BURIAL OR REMOVALY null
DATE OF BURIAL
March IN 1915
" UNDERTAKER
ADDRESS
Chiles fong 19,0
........... ....
(City or town.)
[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.] GRESPRENSA achtwenn RT. fort! Chelwas found
1$ DATE OF DEATH
Mich
(Month)
23
193
(Day)
......... (Year)
6 DATE OF BIRTH
March
26
. 11
mos.
.yrs.
28.
da
Of ......... min. ?
-
Brother
....
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 Ilouse- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At schoolor 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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