USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 26
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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 septicacmia," " 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.
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
! PLACE OF DEATH Ma Chelmsford ...... (No. Gay
St. :
........ Ward)
191 No. Chelmsford. foi or town.y {If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Maler White
+ COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married.
16 DATE OF DEATH
March 28
(Month)
(Year)
6 DATE OF BIRTH
April 29, 1840
(Month)
(Day)
(Year)
7 AGE
72 yrs. 10 mos. 27
ds.
or
.......
min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
Retired
9 BIRTHPLACE
(State or country)
Danverer Mars
(Duration) ....
.... yrs.
mos.
6
ds.
Contributory
Brughli Descene
(SECONDARY)
(Duration)
not Knowmy
(Signed)
JE Vanner
M.D.
mich 20 1913 (Address) n Conhunter
* 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
Riverside Semesters.
No. Thelmafordi
DATE OF BURIAL
March 3/ 1913.
(Address) Lowell Mack
16 Filed May 31, 1913 Edward Spotting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
Mck. 22 1913 to Mich 28
1913
that I last saw him alive on ...
Milch 28
. 1913
and that death occurred, on the date stated above, at 6300m
The CAUSE OF DEATH* was as follows :
Usassua
10 NAME OF
FATHER
Louis Rifley.,
PARENTS
11 BIRTHPLACE- OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER Sophia Gardner,
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Gro. H. Pichler.
:0 UNDERTAKER
GromHealey.
ADDRESS
79 Branch Of.
Royal Jo Ripley.
2 FULL NAME [If married or divorced Woman or widow give maiden name, also pame of husband.I @RESIDENCE No. Chelmsford
Registered No.
20
(Day)
1913,
....
.
....
If LESS than
I day. ....... hrs.
.. yrs.
mos.
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) 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 Hlousc- 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 bo 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 tho 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.
ยท 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.
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 classifled. Exact statement of OCCUPATION is very
The Commmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
2 FULL NAME.
Harmo
[If married or divorced woman or widow Wurde Gence of South
give maiden name, also name of husband.]
@RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
-
Female White
4 COLOR OR RACE
6 SINGLE,
MARRIED, Unaved
WIDOWED
OR DIVORCED
(Write the word)
1
(Year)
7 AGE
72
.yrs.
3
20
mos
ds.
or ........ min. ?
8 OCCUPATION
(e) 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)
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE
OF FATHER
(State or countrys
Hranextru
12 MAIDEN NAME
OF MOTHER
Vary Healey
18 BIRTHPLACE
OF MOTHER
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informent).
Ser H. Damitte
(Address) No blenretard
16
Filed Ofy. 3 1913 Edward & Robbins
REGISTRAR
...
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
march 2
1913
, to .. March 30, 1993 ..... that I last saw him alive on March 30, 1913. and that death occurred, on the date stated above, at. ..........
m. The CAUSE OF DEATH* was as follows :
acute yellow atrophy
of Liver
0
.(Duration).
..........
... yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration)
.... yrs.
mos.
..........
ds.
(Signed)
1.71, Leland
M.D.
March 36 191.3. (Address).
Lower Mass
* 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.
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
Riverside ben Hur 3
1919
ADDRESS
20 UNDERTAKER
Nembech Conell,
192
(City or town.)
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No. 21
16 DATE OF DEATH
march.
1
30 -
1913
6 DATE OF BIRTH
De0 11 1940
(Month)
(Day)
If LESS than
1 day, ..
hrs.
MARGIN RESERVED FOR BINDING
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 cach 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 ro- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, 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 " (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 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 important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Hannah Stevens
Sveta Sichneed Alevens
Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
april
+
14
191
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that i attended deceased from x
...... ,
1913
1913
that I last saw halive on
Flasch 31
1913
and that death occurred, on the date stated above, at a m.
The CAUSE OF DEATH* was as follows :
Canon of stomach
(Duration)
yrs.
mos.
ds.
Contributory .. (SECONDARY)
.(Duration).
.... yrs.
mos.
... ds.
(Signed)
JE Vanty
M.D.
april 1, 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.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
( Informant).
(Addres D Valededucted
16
Filed ahr. 3, 1913 Edward & Bobbing
......
193
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
1 PLACE OF DEATH
2 FULL NAME
[If married or divorced woman or widow
give maiden nar
@RESIDENCE
3 SEX
circle
4 COLOR OR RACE
5 SINGLE,
MARRIED,
while
6 DATE OF BIRTH
five 17
(Month)
7 AGE
5'8
8 OCCUPATION
particular kind of work
(b) General nature of industry.
business, or establishment in
which employed (or employer) ..
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER/
PARENTS
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
Trade ,
Athome
185.4
(Day)
1
(Year)
If LESS than
1 day ......... hrs.
yrs.
9 mos. 14
or ........ min. ?
........
9 BIRTHPLACE
(State or country)
ntra North ctdans
10 NAME OF
Charles Sorvetes
ateliers
13 BIRTHPLACE OF MOTHER (State or country) England
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
1913
20 UNDERTAKER
ADDRESS
St. : Ward)
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
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 "Lahorer," "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 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 heginning of illness. If retired from husiness, 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 cerehro-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, peritonacum, etc., Carcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasmc) ; Measles ; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not he stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (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 he ascertained as the cause. Always qualify ali diseases resulting from childhirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1
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.
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
Arthur & Martin
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also pame of husband.]
@RESIDENCE
Cheminford Masz
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
& DATE OF BIRTH
bul 19 1903
1
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day ......... hrs.
or
.min. ?
8 OCCUPATION (a) Trede, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) ..
Gastritis
(Duration)
........... yrs.
mos.
ds.
Contributory ..
(SECONDARY)
(Duretion)
yrs.
mos.
... ds.
(Signed)
Wilfrid ). Burke
M.D.
afer
,1913 (Address) 509 Wymais Exchange
* 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 deeth
.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
dime Idice
DATE OF BURIAL
191.5
Filed. apr. 5 1913 Edward & Robbing
16 DATE OF DEATH
191.3
(Month)
(Day)
(Year)
17
1 HEREBY CERTIFY that I attended deceased from
Jar 31, 1913, to afe H
1913
.. ,
that I last saw himalive on.
afe 4
1913
and that death occurred, on the date stated above, at 630m.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER Lecere &Sargent
13 BIRTHPLACE OF MOTHER (State or country> Gowell
wellhave
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informen Venduvel Martin (Address) Gulhuelad
194
(City or town.)
[If death occurred in a hospitel or institution, give its NAME instead of street and number.]
St. : Ward)
20 UNDERTAKER
ADDRESS
important. See instructions on back of certificate.
9
yrs.
9
mos.
16
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 oach 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 fircman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples : (a) Spinner, (b) Cotton mill; (a) 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, Laborcr - 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 DEATII, 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, writo 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 uso of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
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