USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 29
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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
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., 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.
8. 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
MONSON MASS. (City or town.)
1 PLACE OF DEATH
(No Copilapatie Nostoccol, St.
Ward)
[If death, occurred in a hospital/or .institution, give its .NAME instead of street and number.]
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.} Bridgett Mc Simac aRESIDENCE No Conclusfordullors
Registered No.
321
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Precoce Mente
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widow
6 DATE OF BIRTH
(Month)
(Day)
(Yeary
7 AGE
If LESS than
1 day ......... hrs.
66
yrs. mos. ds.
or ......... min. ?
& 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 country)
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Da Thour und
(Address)
Palmer ellos
16 Filed Lecceszef 193
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
1913
(Month)
(Day)
(Year)
184 17 I HEREBY CERTIFY that I attended deceased from May 5, 1913 to altay 24, 1913
that I last saw her alive on
clay 73, 1913
and that death occurred, on the date stated above, at 4:30 am.
The CAUSE OF DEATH* was as follows :
opleprey
.. (Duration) 1
... yrs.
.mos.
ds.
Contributory Atemoribaya for Hours
(SECONDARY)
.. (Duration)
yrs.
.. mos.
....... ds.
(Signed)
Morgan B Hodetling
M.D.
Zeca × 24/013
(Address).
Patines ellos
* 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.
1yrs ..
f mo
.mos, 3 ds.
State
.yrs.
In the
mos.
ds.
Where was disease contracted, If not at place of death ?..
Former or
usual residence ..
19 PLACE OF BURIA O STRIAS OR REMOVAL
DATE OF BURIAL
May-1913.
.............
20 UNDERTAKER
Suc Places
ADDRESS
important. See instructions on back of certificate.
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
MARGIN RESERVED FOR BINDING
PARENTS
-
203
Priclast Sorelline W/C. Classe
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 he 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 he 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,""Dealcr," 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., C'arcinoma, 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 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 " (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 childhirtli 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 disahlcd 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
204
(City or town.)
[If deeth occurred In a hospital or institution, give its NAME Instead of street and number.]
FULL NAME
Minnefred V. Jako
[If married or divorced woman or widow
give maiden name, also name of husband.]
aRESIDENCE 29 Parkman St. Boston mars
Irving- Edward & Jafe
0
Registered No. 33
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
1
4 COLOR OR RACE
gr.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Alec
(Month)
(Day)
1886
(Year)
7 AGE
If LESS than
I day ......... hrs.
26
...... yrs.
5
.. mos.
28 ds.
or ......... min. ?
8 OCCUPATION (a) Trede, profession, or particuler kind of work :.
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
-At home
9 BIRTHPLACE
(State or country)
Boston Maso
10 NAME OF
FATHER
Edward Ering
11 BIRTHPLACE
OF FATHER
(State or country)
Mama:
12 MAIDEN NAME
OF MOTHER
Bright Manning
18 BIRTHPLACE
OF MOTHER
(State or country)
Cambridge
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Edwards, Tape
(Address)
29 Parteman St Boston
Filed May 31, 1913 Eduard), Rubbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
1$ DATE OF DEATH
28
I HEREBY CERTIFY that I attended deceased from 17 January 1, 1913, to april Int. 1913. that I last saw her alive on. ......... april ist, 1913. and that death occurred, on the dato stated above, at ..................... m. The CAUSE OF DEATH* was as follows ; Tuberculosis of Lunga and-
Vanced etage when & laste
saw patient
(Duration)
6
... mos.
... ds.
yrs. ....
Contributory ..
(SECONDARY)
(Duration)
............
.... yrs.
mos.
ds.
(Signed)
.......
Will Srell
M.D.
Dax 30
19105 (Address).
Boston mans ......... .... 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 of usual residence. ......
19 PLACE OF BURIAL OR REMOVAL Holy Cross Malden
DATE OF BURIAL
May 31, 1919
20 UNDERTAKER
ADDRESS
Ger. L. Doherty 169 Kaslungtrust,
1912
....
(Month)
(Day)
(Year)
1
...
PARENTS
1 PLACE OF DEATH
.St. ;.
.......... .Ward)
......
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 , 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 operatiou 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.
F
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX male 6 DATE OF BIRTH 7 AGE 8 OCCUPATION (a) Trade, profession, or particular kind of work (b) General nature of industry, business, or establishment in which employed (or employer). PARENTS important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY, PHYSIon hould state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 0 yrs.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford
(No.
actor Sh
St. :
.... . .... .
Ward)
(City/or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
34
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Han
8
(Day)
(Year)
Dre.
29
1912
(Month)
(Day)
(Year)
If LESS than | day, ........ hrs.
0
mos.
10
ds.
........ min. ?
.
-
9 BIRTHPLACE
(State or country)
Chelmsford
10 NAME OF
FATHER
James a. Simpson
11 BIRTHPLACE OF FATHER (State or country) Nova Scotia
12 MAIDEN NAME OF MOTHER Hattie Q. Emery
13 BIRTHPLACE
OF MOTHER
(State or country)
So Berwick, The.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
James a Simpson
(Address) Chelmsford
Filed Jan 9 1913 Edward . Golfing
REGISTRAR
17
I HEREBY CERTIFY that
attended deceased from
Dia 29, 199, to
Jan 8
1913.
that I last saw hasme alive on
Han 8
.... 1913
....... .
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)
Autor y ferboria
M.D.
(Signed)
Jan, 9, 1913
(Address)
.......
*Vf 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).
In the
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.
1 PLACE OF BURIAL OR REMOVAL Pine Ridge Com
DATE OF BURIAL
191.3
10 UNDERTAKER
Walter tenham
ADDRESS
Chelmsford
......
191.3 .
4 COLOR OR RACE
white
5 SINGLE
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
FULL NAME Cheater James Simpsons [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
205 Chelmsford ...
MARGIN RESERVED FOR BINDING
.....
yrs.
.mos.
ds.
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, c. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary firemun, etc. But in many cases, especially in industrial employments, it is necessary to know (¿) 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) Salcs- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the sccond 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 ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritondenn, 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 strect, or one supposed to le due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH West Chelmsford ( No.
St. : .
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
lelara m lade
[If married or divorced woman or widow
give maiden name, also name of husband.]
a RESIDENCE West lehetneford
Married Wilfred lerle
Registered No. 35
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
finale
4 COLOR OR RACE
white
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
6 DATE OF BIRTH
2
19.3
17
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day. ....... hrs.
29 .yrs. mos. 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)
Lakeport n. H.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Rochester N. A.
12 MAIDEN NAME
OF MOTHER
Estella Henakino
13 BIRTHPLACE
OF MOTHER
(State or country)
ashland UN
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Worked leale
(Address)
Weer Chelmsford
16 Filed June 15, 1913
Edward & Retting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
June
13
193
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
Same 2, 1913 to june13
1913
.... .
that I last saw h / alive on.
ferme 13
1913
and that death occurred, on the date stated above, at ..
80 m.
The CAUSE OF DEATH* was as follows :
(Duration)
yrs.
mos.
13
ds.
Contributory .. (SECONDARY)
(Duration)
.. yrs.
mos.
ds.
(Signed)
JE Varney
M.D.
Am 14. 1919 (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.
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
20 UNDERTAKER
ADDRESS
206
(City or town.)
MARGIN RESERVED FOR BINDING
10 NAME OF
FATHER
Henry a Briggel
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 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 : («) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the sccond statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coal mine, ete. 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 bo 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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