USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 31
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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
w 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 corobro-spinal meningitis ") ; Diphtheria (avoid nse of "Croup ") ; Typhoid fever (nevor 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 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 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.
Cases for the Medical Examiners. - Under tho provisions of chapter 24 of the Revised Laws deaths under tho following conditions must be referred to the Medieal 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 Alcoholismi, 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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
11-15No
Princeton
St. :
Ward)
(City or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
40
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
June 30
1973
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from May 10
191 3 to.
........
June 30 19/3.
June 28
that I last saw ha
............. alive on ...
1913
and that death occurred, on the date stated above, at 49 m.
The CAUSE OF DEATH* was as follows :
Congenital debility.
Since birth.
(Duration)
.... yrs.
mos.
ds.
Contributory
(SECONDARY)
7
(Duration)
.... yrs.
mos.
ds.
(Signed)
June 30
1913 (Address).
2. Chelmsford
* 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 Stort
DATE OF BURIAL 30 1918
20 UNDERTAKER
ADDRESS
1 PLACE OF DEATH - ªFULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE hr ChelindaA PERSONAL AND STATISTICAL PARTICULARS 3 SEX 4 COLOR OR RACE Make 5 SINGLE MARRIED WIDOWED, OR DIVORCED (Write the word) 6 DATE OF BIRTH / 170 19/3 0 (Day) (Month) (Year) 7 AGE If LESS than I day ..... hrs. yrs. mos. or ........ min. ? ds. 8 OCCUPATION (a)' Trade, profession, or particular kind of work. 1 (b) General nature of industry, business, or establishment in which employed (or employer). 9 BIRTHPLACE (State or country) Massaro achucette 10 NAME OF FATHER < 11 BIRTHPLACE OF FATHER (State or country) Mascrehosté 12 MAIDEN NAME OF MOTHER & A. Magnant PARENTS 13 BIRTHPLACE OF MOTHER (State or country) Connecticut 14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE àthe (Informant). CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back of certificate. (Address) N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state ....
15 Filed Ine 30, 1913 Edward S Room
REGISTRAR
211
M.D.
In the
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preciso statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can bo 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) tho nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when necded. 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. Nover 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 employcd, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic servico 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 bo 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 samo 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, peritonacum, etc., Carcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," " Convulsions," "Debility " ("Congenital," "Senile," otc.), "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 disablod 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
1 PLACE OF DEATH Chelmsford
.(No. Chela fund Centre St. :
Ward)
212 Chelnlund
(City or town.)
[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.] @RESIDENCE
Chelifuel
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Le
4 COLOR OR RACE
5 SINGLE MARRIED WIDOWED, OR DIVORCED (Write the word)
6 DATE OF BIRTH
2H
(Day)
-
(Year)
7 AGE
If LESS than
I day, ........ hrs.
... yrs. -mos. 8 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).
(Duration)
.yrs.
mos. ds.
Contributory IL ASECONDARY)
(Duration) .yrs.
mos. ds.
HU. Maya
M.D.
(Address).
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.
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 Enbil 2 1913
20 UNDERTAKER Archambaud
ADDRESS
738
15 Filed .. July 2, 1913 Edward J Raffin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
(Month)
(Day)
191.2 (Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
that shake
9 BIRTHPLACE
(State or country)
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Canada
12 MAIDEN NAME
OF MOTHER
quele Premier
13 BIRTHPLACE OF MOTHER (State or country)
-Pomada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Tachir
(Address)
138 Nummer
STANDARD CERTIFICATE OF DEATH neen
Glin B. L'Heureux
Registered No.
41
Muunmack
10 NAME OF
FATHER
Yough G. 8 Heuresil V, 1913
(Signed)
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 eachi and every person, irrespective of age. For many occupations . a singlo word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and thereforo an additional line is provided for the latter statement ; it should be used only when needed. As examples: (() Spinner, (3) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The matorial 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 wlio receive a definite salary), may bo 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 sorvice 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 dofinite 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 indefinito) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. ........ . (name origin : " Cancer " is less definite; avoid use of "Tumor " for malignant nooplasms) ; 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. 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 undor 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.
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
hemsford mass.
(No.
St. :
Catharina Im" Nulty
2/3
(City or town.)
[If death occurred in a hospital or institution, giva its NAME instead of street and number.]
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Cast
Chemsford Imass?
Registered No. 42
.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Amale arhite
4 COLOR OR RACE.
1 5 SINGLE,
MARRIED,
WIDOWED. -
OR DIVORCED
Write the word)
Single
6 DATE OF BIRTH
? AGE
If LESS than
1 day, ....... hrs.
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)
Fast Cheromford henares
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or countsyf most Chemoford
12 MAIDEN NAME OF MOTHER Ella Pourfe Course
18 BIRTHPLACE OF MOTHER
1
(State or country) Cowell frank)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 7 George W. Min- NulLis
0
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
June 24, 199 t
July 5
1912
that I last saw her alive on
1913
and that death occurred, on the date stated above, at 3 0.
.m.
The CAUSE OF DEATH* was as follows :
Spina Bifida
(Duration)
... yrs.
.. mos.
ds.
Contributory
(SECONDARY)
.(Duration) .yrs.
mos.
ds.
trang Boyle
M.D.
(Signed)
7~15/
1910 (Address) whyple 8
* 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
(Informant) .......... d'art Cheme And Smart St. Variske July F. (Address)
+ UNDERTAKER
ADDRESS
70 yor han
191
16 Filed July 7, 1913 Edward & Rotting
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
(Month)
(Day)
1913
(Year)
(Month)
(Day)
1
(Year)
.yrs.
mos.
// ds.
Ward)
In tha
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 moro 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 tho 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: Cercbro-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 lcss 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," 6ª 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 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 Chelmsford Mas Off Billerica St. : Ehnur Gleworth Hildreth
214 Chelmsford (City ør town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
43
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
m
4 COLOR OR RACE
W.
5 SINGLE
MARRIED,
(Write the word)
6 DATE OF BIRTH
Upv.
7
1870
(Montlı)
(Day)
(Year)
7 AGE
If LESS than I day, ........ hrs.
43
yrs.
3
mos.
ds.
or ........ min. ?
-
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
Hammer
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE
(State or country)
ry Chelmsford
(Duration).
.. yrs.
mos.
ds.
Contributory
Myocarditis
(SECONDARY)
.(Duration)
Arthur G. Sestoria
*........... yrs.
mos.
ds.
M.D.
(Signed)
Jul 14.
191 3 (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.
In the
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence. ......
DATE OF BURIAL
(Informant)
Mo. EE Hiedutti
(Address)
Chelmsford
Filed July 14, 1913 Gdevard J. Rolling
REGISTRAR
16 DATE OF DEATH
/
(Month)
(Day)
1913
(Year)
17
161
...... , to
-I HEREBY CERTIFY that I attended deceased from
Jacky /1, 1913.
that [ last saw h ....
alive on
July 11, 193
and that death occurred, on the date stated above, at 20m.
The CAUSE OF DEATH* was as follows :
Chronic Parenchy matous
nephritis.
10 NAME OF
FATHER
Benj. Hildredde
PARENTS
Il BIRTHPLACE OF FATHER (State or country) Chelenstand
12 MAIDEN NAME OF MOTHER Mary Ce. elogalin
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
19 PLACE OF BURIAL OR REMOVAL Forestathis Cerny July 14
...
191
3
ADDRESS
20 UNDERTAKER
Walter Perkam Chelmsford.
important. See instructions on back of certificate.
Ward)
2FULL NAME [If married or divorced woman gr widow give maiden name, also name of husband.] @RESIDENCE Chemetal
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, Arehitcet, 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 Housc- 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.
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