USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 30
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
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 discase. Examples: Cercbro-spinal fever (tho only dofinite synonym is "Epidemie ccrebro-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, ete , Carcinoma, Sar- eoma, etc., of .. .... (name origin: "Cancer" is less definito; avoid use of " Tumor " for malignant neoplasms) ; Measles ; Whooping cough; Chronic valvular heart discase; 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- acmia " (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 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 violenco, 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.
1
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 Quit hulu forse 259 farligles John J. Meagher
'FULL NAME [If married or divorced woman or widow give maiden name, alse name of husband.] @RESIDENCE
259 Carlisle St, Chelidard
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male While
4 COLOR OR RACE
1 5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word).
Medowed
6 DATE OF BIRTH
..
(Month)
(Day)
...
(Year)
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
at Home/
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Ireland
10 NAME OF
FATHER
Tennis Meagher
11 BIRTHPLACE
OF FATHER
(State or country)
Suland
12 MAIDEN NAME
OF MOTHER
annie Cormack
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
" THE ABOVE IS, TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mis M. S. Mega
18 Filed Jane 16, 1913 Edward J. Rothing
REGISTRAR
1ª DATE OF DEATH
X une 103
191
used (Month) / (Day) /(Year)
I HEREBY CERTIFY that I attended deceased from Jau au /2, 1993 to A4Que 12, 1913
that I last saw h - 2 % alive on ........ fuel 12 1913 and that death occurred, on the date stated above, at /13 cm.
The CAUSE OF DEATH* was as follows :
Quaility
.. (Duration)
.... yrs.
... mos. ds.
Contributory ........
(SECONDARY)
.(Duration)
.... yrs.
mos. ds.
(Signed) 1.00. 1912 (Addres).
* 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). . in the
At place
of death ..
... yrs.
.. mos ..
.. ds.
State ...
.......... yrs.
.ds. .... ...... Where was disease contracted, If not at place of death ?.
Former or
............... .... usual residence ..
DATE OF BURIAL
(Address) 269 Job lisle It Behelye Soc Var St. Patrickes Lem Surge/ 16 1913
207 E Chelmsford (City or town.) - fif death occurred/In a hospital or institution, give its NAME instead of street and number.]
St. :
Ward)
Registered No.
36
MEDICAL CERTIFICATE OF DEATH
...
1828 17
If LESS than
I day, ..
„hrs.
85.
...... yrs.
.........
ds.
or ......... min. ?
6
...
....
19 PLACE OF BURIAL OR REMOVAL
UNDERTAKER Das N. MENuno Dowell Muss.
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) Automobilefactory. 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 Ie- 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 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.
8 SEX
Female
....
7 AGE
79
(b) General nature of industry,
business, or establishment in
which employed (or employer).
PARENTS
18 BIRTHPLACE
OF MOTHER
(State or country)
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
....
.yrs.
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widow
6 DATE OF BIRTH
May 9
1834
(Month)
(Day)
1
(Year)
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
At home
9 BIRTHPLACE
(State or country)
Calis Maine
10 NAME OF
FATHER
J. T. Smith
11 BIRTHPLACE
OF FATHER
(State or country)
Nova Scotia
12 MAIDEN NAME
OF MOTHER
ANNA Griffin
Nova Scotia
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(informant).
T. T. Smith
(Address) Chelmsford Centre Mass
15 Filed June 16, 1913 Edward In Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
.........
(Month)
(Day)
191
(Year)
17 I HEREBY CERTIFY that Vattended deceased from March
1912 to 1
June 13, 1913.
that I last saw her
alive on
Aunque 13, 1913.
and that death occurred, on the dato stated above, at .....
.m.
.........
The CAUSE OF DEATH* was as follows :
Diabetes
mellitus
Mary than 1 1/2 years
Contributory.
(SECONDARY)
„ ... (Duration) .
... yrs.
mos.
ds.
(Signed)
Antury, Scoboria
M.D.
hue 1/1, 191 3 (Adres).
....
Chilwestand may.
......
(* 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.
In the
State ............ yrs. ............. mos.
..........
... ds ......
Where was disease contracted, If not at place of death ?.
Former or usual residence. .................................. ......
...........
1 PLACE OF BURIAL OR REMOVAL Lowell Cemetry
DATE OF BURIAL
June 16
....
1913
ADDRESS
20 UNDERTAKER C.M. Young #33 Prescott St.
208
...
(City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
'FULL NAME Emma E Melvin
[If married or divorced woman or widow
give maiden name, also name of husband.] Amma E. Smith
Alonzo I. Melvin
@RESIDENCE
Chelmsford Centre Mass
PERSONAL AND STATISTICAL PARTICULARS
....
St. :
Ward)
Registered No.
37
..........
16 DATE OF DEATH
June 13 1913
.. (Duration) ...
........... yrs.
..........
mos.
ds.
...........
If LESS than
[ day .......... hrs.
7 mos. 4 .. ds.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH 1 PLACE OF DEATH
Chelmsford Centre Magno
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, ctc., 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.
1912 84
1828
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B .- Every Item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford (No. High ..........
St. :
......
.Ward)
'FULL NAME Mary Adame.
[If married or divorced woman or widow give maiden name, also name of husband.] Mary Warling. William Adams @RESIDENCE Chelmsford
Registered No. 38
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
SEX
Female. White
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed.
16 DATE OF DEATH
June
16.1913.
(Month)
(Day)
(Year)
6 DATE OF BIRTH
Sehr.
(Month)
15. 1828
(Day)
(Year)
7 AGE
If LESS than t day ......... .......... hrs.
84 yrs. 9
..... mos. ........
Or ......... min. ?
& OCCUPATION
(a)' Trade, profession, or
particular kind of work.
At Home.
(b) General nature of Industry,
business, or establishment in
which employed (or employer).
At Home.
Hemiplegia.
9 BIRTHPLACE
(State or country)
Scotlands
Contributory ..
(SECONDARY)
..........
.(Duration)
Autun 9. Sectoria
................ yrs.
mos.
.ds.
(Signed)
........
.....
M.D.
June 16, 1913 (Address) Chulaford, Har.
* If death followed injury or violence the certificate of death must be made ont 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
Edson Cemetery, June 18, 1913.
(Informant)
Mang. George M. Wright
(Address) Chelmsford
18 Filed In June 18, 1913 Edward Se Rathaus
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
191
to
apr. 12. 1913
that I last saw ha alive on.
......
... 191. and that death occurred, on the date stated above, at 8: 45 Am. The CAUSE OF DEATH* was as follows :
....
10 NAME OF
FATHER
- Harting.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
Unknown.
13 BIRTHPLACE
OF MOTHER
(State or country)
Scotland
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
.............. ............
............
............. (Duration)
mos.
ds.
...............
...........
ADDRESS
20 UNDERTAKER
Gro Masleales, 79 Branch of
209 Chelmsford. (City or town.) fIf death occurred In a hospital or institution, give its NAME Insteed 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. 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.
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.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
North Chelmsford Deput dl
St. ;..
.............. .. Ward)
Still Barw
'FULL NAME
{If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
I$ DATE OF DEATH
June
20 191-3
(Month)
(Day)
(Year)
6 DATE OF BIRTH
...
0
(Month)
(Day)
19/13 (Year)
7 AGE
If LESS than t dey .......... hrs.
yrs. ... Y mos. ds.
Or ......... min. ?
8 OCCUPATION (a)' Trade, profession, or particuler kind of work ............................................................
(b) Generel nature of industry, business, or establishment in which employed (or employer) .....
9 BIRTHPLACE (State or country) fatto Cheles port
10 NAME OF FATHER Orilla Fallal
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Lawell Man
12 MAIDEN NAME OF MOTHER Regina gandrea
13 BIRTHPLACE OF MOTHER (State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed June 20, 1913 Edward & Robbing
REGISTRAR
...
I HEREBY CERTIFY that I attended deceased from
......
191
to.
. 1913
........
that i last saw her àlive on.
.
................ 191. and that death occurred, on the date stated above, at /130pm. The CAUSE OF DEATH* was as follows :
Still for
(Duretion) .. ............. yrs. mos. ds. ................
Contributory (SECONDARY)
mos. .ds.
(Signed)
from 27, 1913
(Address).
(Duration)
Varre
-
M.D.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At plece
of death.
........... yrs. ............ mos.
In the
.da.
State ............ )[ .. ............ 08.
ds ....
Where was disease contracted, if not at place of death ?.
Former or usual residence ...
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Sido, 1912
20 UNDERTAKER
ADDRESS 138
Of thechambault Musswars
210
....
(City or town.)
[If death occurred În a hospital or institution, give its NAME instead of street and number.}
Registered No.
3
-........
... ,
...... ,
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that tho relative healthfulness of various pursuits can be known. The quostion applies to each and every person, irrespective of age. For many oceupations 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 (6) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or givon 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 (rctired, 6 yrs.). For persons who have no occupation whatever, write None.
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.