USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 28
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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 respcet 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, ete., 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 intereurrent) affection need not be stated unless im- portant. Example: Measles (disease causing deatlı), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatie), " Atrophy," "Collapse," " Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy,""Exhaustion," "Heart failure," " Haemorrhage," " Inanition," "Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident ; Revolver wound of head-homicide; Poisoned by carbolic acid - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of " Contributory."
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, ete.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No .. Newfield
St. :
Ward)
Crackett
Registered No.
28
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
May
6:
1913
....
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
afmet 28, 193, to
Hay 6
1913
that I last saw han alive on.
1913
and that death occurred, on the date stated above, at 11, 15~9.
The CAUSE OF DEATH* was as follows :
Lubescalão
abrati one Je
.(Duration)
............. yrs.
mos. ds.
Contributory.
(SECONDARY)
(Duration).
.. yrs.
mos.
ds.
(Signed)
., 1913 (Address).
HI Chelungers
M.D.
* 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 tha
.
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL no. Chelineford
DATE OF BURIAL
May 9.
1913
.......
15 Filed May 8, 1913 Canard & Robbing
REGISTRAR
199
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
1 PLACE OF DEATH
no. Chelureford
2 FULL NAME
heury 6.
[If married or divorced woman or widow
give maiden name, also name of husbaud.]
@RESIDENCE
no. Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
white
male
5 SINGLE,
MARRIED,
married
WIDOWED,
OR DIVORCED
(Write the word)
5 DATE OF BIRTH
me
8
1852
(Month)
(Day)
(Year)
? AGE
If LESS than
t day. ....... hrs.
60 yrs. 10 mos
28 ds.
or ........ min. ?
8 OCCUPATION
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Sebeck Mains
10 NAME OF
FATHER
Jord Crockett
11 BIRTHPLACE
OF FATHER
(State or country)
Sebeck Mains
12 MAIDEN NAME
OF MOTHER
Esther Perham
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address)
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
(a) Trade, profession, or
particular kind of work
artesian Heel driller
Brownville Staine
20 UNDERTAKER
S. a. Weinbeck
ADDRESS
VG Market St
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," unqualificd, 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.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
7 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 classified. Exact statement of OCCUPATION is very ....
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Forth Chelmsford (No.
Mt. Pleasant
St. :
Ward)
(City or town.) Elf death occurred In a hospital or institution, give its NAME instead of street and number.]
'FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Mt. Pleasant Street Forth Chelunsford
Registered No.
29
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1$ DATE OF DEATH
10
1913
(Month)
(Day)
(Year)
6 DATE OF BIRTH
May
(Month)
10
(Day)
1913
(Year)
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)
Forth Cheles ford Mas
10 NAME OF
FATHER
Uthey G. Mener
11 BIRTHPLACE
OF. FATHER
(State or country)
There Maso
12 MAIDEN NAME
OF MOTHER
alcy I. hagenout
13 BIRTHPLACE
OF MOTHER
(State or country)
Mellemantes Co
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
arthur P. Mener at other
(Address) Inth Chelin ford
Filed May 11, 1913 Edward Reform .........
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
191.
..... , to
May 10, 1993
that I last saw hw alive on.
......
may 10
. 1912
and that death occurred, on the date stated above, at 90 m.
The CAUSE OF DEATH* was as follows :
Congenital de bility
9 hours
... (Duration).
..........
..... yrs.
................ ds.
Contributory
(SECONDARY)
.. (Duration)
.mos.
ds
-
(Signed)
7 E Varney
....
...........
... C
may 11, 1953
..........
(Address).
A Chelungen
* 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 chelu fy If frepho Center
DATE OF BURIAL
May 1/193
20 UNDERTAKER At Dowell Done
ADDRESS
$24 mauset
3 SEX
male White
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
If LESS than + day 8hrs.
-
.yrs. mos. ds.
200 heleaford Pass
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 engincer, 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, Hlousemaid, 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.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX
male
4 COLOR OR RACE
White
7 AGE
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
None,
(b) General nature of industry,
business, or establishment in
Mones
which employed (or employer).
9 BIRTHPLACE
West Chelmsford
11 BIRTHPLACE
OF FATHER
(State or country)
Sweden
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
Sweden
important. See instructions on back of certificate.
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
(State or country)
Massachusetts
15 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Single.
If LESS than
I day, ........ hrs.
yrs.
7 mos.
18 ds.
or ........ min. ?
10 NAME OF
FATHER
Carl Gustave Nystrom
12 MAIDEN NAME
OF MOTHER
Augusta Anderson
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Father, Carl S. Nystrom
(Address) A. Chelmsford. Maser
Filed May 22 1913 Edward & Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
may
(Month )
21
1913
(Day)
(Year)
6 DATE OF BIRTH
October 3
1911
17
I HEREBY CERTIFY that I attended deceased from
(Month)
(Day)
(Year)
May 18
... , 1913 to
May 20
...
191.3 .. ,
that I last saw hun alive on
may 20
1913
-
and that death occurred, on the date stated above, at / P.m.
The CAUSE OF DEATH* was as follows :
Intussusception
(Duration)
yrs.
mos.
3
ds.
Contributory .. (SECONDARY)
(Duration)
yrs.
.mos.
ds.
(Signed)
Q1 week
M.D.
May 21, 1913 (Address) Heelhard, Mas
* 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.
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
West Chelmsford
DATE OF BURIAL
May 22, 1913.
20 UNDERTAKER
Gro Mealeys
201 Chelmsford. (City or town.y [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Ward)
Walter Edward Nystrom
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Hest Chelmsford mars
Registered No. 30
PERSONAL AND STATISTICAL PARTICULARS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH 1 PLACE OF DEATH West Chelmsford .(No
St. :
In the
ADDRESS Lowell, Masa, 79 Branch &&
-
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 minc, 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, peritoneum, etc., C'arcinoma, 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.
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 important. See instructions on back of certificate.
8 OCCUPATION PARENTS 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 + 6 helmeford (No
.... Parkhurst
St. :
.......................
.Ward)
Robert J. Elemente. FULL NAME {If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Parkhurst St., Chelmsford Center, Mace Registered No. 31
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male.
4 COLOR OR RACE
White.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single.
6 DATE OF BIRTH
Sept,
....
(Month)
(Day)
27. 1875.
(Year)
7 AGE
37 Jul. 2 mos.
mos.
26 de.
If LESS than
I day, ......... hrs.
er ......... min. ?
(a)' Trade, profession, or
particular kind of work
Treas. Tucker Parker ho
(b) General nature of industry.
business, or establishment in
which employed (or employer) ..
Electriciane
9 BIRTHPLACE
(State or country)
Lowell, Mass.
10 NAME OF
FATHER
Robert J. Clements.
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland.
12 MAIDEN NAME
OF MOTHER
Sarah A. Wagner.
18 BIRTHPLACE
OF MOTHER
(State or country)
Mass.
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mora. Sarah A. Clemente,
(Address) Chelmsford Center Mars.
18 Filed. may 24, 1913 Edward J. Rothis
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
may
23
1953
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
May 23, 193
that I last saw h Mutlive on.
mark 19, 1993.
and that death occurred, on the date stated above, at //m.
The CAUSE OF DEATH* was as follows :
Carcinoma Carci
........
(Duration).
8
... yrs. .............. mos. ....... ds.
Contributory ..
.......
(SECONDARY)
0
ds
....... (Duration)
.. yrs.
.. mos.
(Signed)
Calliaus
Mars 23 1913 (Address)
* If death followed injury or violence the certificate of death must be made ont bý 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.
...... ......... Where was disease contracted, If not at place of death ?. .... Former or usual residence
1º PLACE OF BURIAL OR REMOVAL Edson Cemetery.
DATE OF BURIAL
May 25, 1918
20 UNDERTAKER
GromHealey.
ADDRESS
79 Branch St.
202 Chelmsford. (Gity or town.) [If death occurred la a hospital or institution, give ita NAME Instead of street and number.]
......
.......
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.
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