USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 27
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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 torminal 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 canse 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 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
1PLACE DE DEATH Mouth (Relais ford ( No. Con Edance and his istaton
Halque
'FULL NAME {If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Con Udac and Premicity . Forth Chaleurs ford
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
apul & 19.13.
(Month)
(Day)
(Year)
If LESS than
I day, .........
..... yrs. ... mos. da.
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)
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or conntry)
Salbatice Maine
12 MAIDEN NAME
OF MOTHER
Mary J. Doherty
18 BIRTHPLACE
OF MOTHER
(State or country)
Ist chelux ford
18 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Law I. Shabry ophy
(Address)
Youth Cheluisford
18 Filed 6 april 10, 1913 Edward &. Rotfl. ......
REGISTRAR
16 DATE OF DEATH
(Month)
8
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
-
191.
........ , to
191
that I last saw h ............. alive on
191
and that death occurred, on the date stated above, at.
... m.
The CAUSE OF DEATH* was as follows :
Prem
Buth
Child was dead at least 4/6 hrs
Reform birth .. (Duration). ........... yrs. ... mos. ....... ds.
Contributory. (SECONDARY)
......
..........
(Duration) ferment thatany
... yrs.
... mos.
..................
M.D.
(Signed)
ahr 9, it
(Address) ........
chelmalo
* If death followed injury or violence the certificate of death foust be made ont by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
In the
of death.
...... yrs.
.......
... ds.
State.
.. mos.
Where was disease contracted, if not at place of death ?.. ... Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL If Gating Counter
DATE OF BURIAL
" UNDERTAKER
tot. I amwall
ADORESS
324 MayNot
SEX male " AGE 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 classifled. Exact statement of OCCUPATION is very ....
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
PERSONAL AND STATISTICAL PARTICULARS
195 Chelicisford
St. ;..................... Ward)
City or town.) [If death occurred În a hospital or institution, give its NAME .Instead of street and number.]
Registered No.
1913
................
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.
-
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford (No .. Boston Rd. ....
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2FULL NAME Octavia Larcon Varklart
Laren/ S. K. Parkhunt
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED
female
WIDOWED,
OR DIVORCED
(Write the word)
White
(Month)
(Day)
7 AGE
85
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work.
arhouse
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Beverly
11 BIRTHPLACE
OF FATHER
(State or country)
Beverly
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
France
(Informant)
EFF Parkhunt
important. See instructions on back of certificate.
(Address)
Chelmitinis
16
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.
10
mos. ...
7
ds.
If LESS than 1 day ......... hrs.
. ........ min. ?
10 NAME OF
FATHER
Benjamin Larcon
12 MAIDEN NAME OF MOTHER Louise Barrett
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Filed Cfr. 18 913 Edward . Robbing
- REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
aper.
16
1913.
(Year)
(Month)
(Day)
6 DATE OF BIRTH
June
8
1827
17
I HEREBY CERTIFY that I attended deceased from
(Year)
March 6
. 1913, to
...........
apr. 16
. 1913.
....
that I last saw her alive on.
apr. 16
... 1913.
and that death occurred, on the date stated above, at 2:20am.
The CAUSE OF DEATH* was as follows :
Epidemia Influenza
.. (Duration)
.... y. //2 mos.
ds.
Contributory
Senility-
(SECONDARY)
.(Duration)
.......... yrs.
.mos ..
ds.
(Signed)
AntiG. Scotone
....... 1
M.D.
aprin, 1913 (Addres).
* If dcath 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.
............ mos ..
In the
......... ds ...
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Horefactors Cous
DATE OF BURIAL
abril 18, 1913
ADDRESS,
· UNDERTAKER
Walter Erhan Chelmsford
196 Chelmsford ....
(City or town.)
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
Widows
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, peritoneum, etc., Careinoma, 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 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 Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Lowell, Mass. (No. Lowell General Hospital St .; Ward)
197
Love 11
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Beatrice Naylor
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
West Chelmsford, Mass.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED Single
(Write the word)
16 DATE OF DEATH
May 3
191 3
(Month)
(Day) (Year)
6 DATE OF BIRTH
-18911
(Month)
(Day) (Year)
7 AGE
If LESS than I day, ........ hrs.
21
-
mos. ds
or ......... min. ?
· OCCUPATION
(a) Trade, profession, or
particular kind of work ...
Student
(b) General nature of industry, business, or establishment in which employed (or employer).
Acute Appendicitis and Peritonitis
.(Duration)
1
mos.
1
ds.
Contributory ..
(SECONDARY)
(Duration)
.yrs.
mos.
ds.
(Signed)
0. V. Wells
M.D.
May 4, 191 3 (Address).
Westford. Mass.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
In the
of death.
yrs.
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
West Chelmsford, Mass. May 5, 1913
20 UNDERTAKER
Filed ... May 5, 191 3
vale C. M. Young REGISTRAR
ADDRESS
33 Prescott st.
Lowell.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) West Chelmsford, Mass
12 MAIDEN NAME
OF MOTHER
Sussie M. Stearns
13 BIRTHPLACE
OF MOTHER
(State or country)
Springfield, Mass.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Charles F.Naylor
(Address)
W. Chelmsford, Mass.
17
I HEREBY CERTIFY that I attended deceased from
April 2, . 1913 to May 3.
1913
that I last saw her alive on May 2.
.
1913
and that death occurred, on the date stated above, at 5 am.
The CAUSE OF DEATH* was as follows :
º BIRTHPLACE (State or country) Springfield, Mass.
10 NAME OF
FATHER
Charles F. Naylor
yrs.
.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, 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 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, Sur- coma, etc., of. ..... (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (sccond- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraenia," "Weakness," ctc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septieaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminul Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deathis of persons not disabled by recognized disease, as A death upon the street, or onc. supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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
Burkseks Cottage (No Battis Sind
Groupe a. Lindsay
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
12 Bagley av.
Lunes
Registered No.
27
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
Married
1870
(Year)
If LESS than
I day, ........ hrs.
or ........ min. ?
Rockburn
Canada
William Lindsay
Elizabeth Montgomery
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)
I2 Bagley Avenue
16 Thay 9, 1913 Edward J. Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
may
6
(Month)
(Day)
1913
(Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
Juicide
Ey Hanging.
(Duration) .
... yrs.
mos.
ds.
Contributory ..
(SECONDARY)
(Duration)
... yrs.
.. a.mos.
. . ds.
(Signed)
tas 9
1912 (Address).
160 Never
...
M.D.
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.
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
Rockburn
Canada
DATE OF BURIAL
May
9. 1913
20 UNDERTAKER
b.m. chung
ADDRESS
33 Prescott of
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
1 PLACE OF DEATH
So. Chelmsford
3 SEX
4 COLOR OR RACE
Male
White
6 DATE OF BIRTH
Sept
T5
(Month)
(Day)
7 AGE
2I
yrs.
8 OCCUPATION
(a) Trade, profession, or
Contractor
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
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or eountny)
Scotland
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
42
7
.mos.
ds.
(Informant)
Mrs
G. A. Lindsay
-
198 So Chelinaford (City or town.) [lf death occurred in a hospital or institution, give its NAME instead of street and number.]
Ward)
Filed. T
17
In the
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits ean 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, (3) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, 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 faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
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