USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 32
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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 fcver (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) ; Tubcr-
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 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- 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 Examinors:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deathis 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 uuder 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 Cheenfach .(No Usthud Road Ward)
215 Chelming (City or toàn.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
William H. Patterson 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 163 Chelmsford h.
Registered No.
44
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE Male. White
SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(With the word)
Married
6 DATE OF BIRTH Jeff Monthly (Day)
1881 17
(Year)
7 AGE
If LESS than I day, ........ hrs.
......
-
_. yrs.
10 mos 10 ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Iceman
(b) General nature of industry, business, or establishment in which employed (or employer). 8 ceman em
Contributory ..
(SECONDARY)
.. (Puration)
... yrs.
.mos.
ds.
I.V. Cheias
M.D.
(Signed)
July 15.
191 .... (Address) ..
Mothermack 11.
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
In the
of death
yrs.
mos.
ds.
State
...
... yrs.
mos. ...
.ds
....
Where was disease contracted, if not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Edson Cemetery.
DATE OF BURIAL
July 18, 1913,
(Address)
Sowell, Mbres
16 Filed July 18, 1913 Edward S Robbing
LREGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
(Month)
(Day)
.. , 1913 (Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
Dencide ty Hanging
(Duration)
.yrs.
mos.
ds.
9 BIRTHPLACE
(State or country)
Canada.
10 NAME OF
FATHER
Robb. S. Patterson.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Canada.
12 MAIDEN NAME
OF MOTHER
Elizabeth Mac Lees.
dece.
13 BIRTHPLACE OF MOTHER (State or country) Ireland.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. Mary Patterson,
Howell Mase
20 UNDERTAKER
GromHealey
ADDRESS 79 Branch Sr.
14
Thales
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 linc is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (3) Cotton mill; (a) Sales- man, (b) Grocery ; (a) 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- kecpers 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- neumonia (" 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 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- 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 (o. 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, 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
1PLACE OF DEATH
grace noble
FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
grace Wallis Willian noble
Surfin Rd, no Fachustorel.
Registered No. 45
/PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Le
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Thiden
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
I day .......... hrs.
.............. yra. ......... mos .. „ds.
8 .......... min. ?
8 OCCUPATION athome
(a)' Trade, profession, o
particular kind of work .....
(b) General nature of Industry.
business, or establishment in
which employed (or employer) .....
9 BIRTHPLACE
to goy glaston n. B.
PARENTS
12 MAIDEN NAME
13 BIRTHPLACE OF MOTHER (State or country)
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Howard nolle
(Address) no Chelmsford,
Filled. Sinh. 12 1913 Edward Sub Sitting
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
June 20, 1913, to
.......
July 17
1913
that I last saw h ....... alive on.
Ulue 17
1913
-
and that death occurred, on the date stated above, at 9/ m.
The CAUSE OF DEATH* was, as follows :
Dessullegia
...
......
.......
(Duration)
yrs. ..............
... mos.
27
ds.
Contributory ...
(SECONDARY)
(Duration)
............... yrs.
(Signed)
JE Varney
M.D.
fry 19.
. 1917 (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.
Stato ............
...... 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
Ellen, Forel July 20195
" UNDERTAKER
ADDRES'S/
.
Livele
..............
St. ;................
Ward)
2/6 Hothelmy
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Only
17
1913
(Month)
(Day)
.... .
(Year)
....
10 NAME OF
Ency Wallis
11 BIRTHPLACE OF FATHER (State or country) $22.12.
-
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preciso 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 iu 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 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- 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.
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
2 FULL NAME. James H. White
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Hinsdale .W
Registered No.
46
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
14 COLOR OR RACK
white
5 SINGLE
MARRIED
WIDOWED,
deugle
1
(Year)
TAGE
11
yrs. mas. ds. Or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Studiu
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Hinsdale hitt
PARENTS
12 MAIDEN NAME OF MOTHER Elizabeth A limunghan
13 BIRTHPLACE OF MOTHER (State or country)
Hinsdale n.17
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Muchael & White Carta
Address) Hinsdale O. H
15 July 18 1913 Edward Y. Roborna
REGISTRAR
:4
16 DATE OF DEATH
2
(Month)
18
1913.
(Day)
(Year)
17 July
I HEREBY CERTIFY that I attended deceased from
17. 1913, to
July 18, 19/3,
that I last saw hamalive on. Yes 18, 1913 about ya. m. and that death occurred, on the date stated above, at .....
The CAUSE OF DEATH* was as follows :
Gastro Enteritis
auto intoxication
.(Duration) .
... yrs.
mos. ds.
Contributory .. (SECONDARY)
.(Duration) . ... yrs.
mos.
ds.
Arthur J. Scoloria
(Signed)
M.D.
July 18, 1913 (Address)
Chihusford, mass.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
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 BLICE OF BURIAL OR REMOVAL St Vore the Cemetery Hinsdale Rift.
DATE OF BURIAL
July 2/ 199
ADDRES 20 UNDERTAKEB Ut Nouvel Hous Lowill Pass
2170 Chelmsford
Ward)
(City of town.) Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
6 DATE OF BIRTH
0
(Month)
(Day)
If LESS than
[ day, ....... hrs.
10 NAME OF
FATHER
michael & white
11 BIRTHPLACE OF FATHER (State or country) northfield Anase
....
(Write the very
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 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.
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
(No.
0
Zarcele St
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Hattie Elizabeth adama
2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Cholesterol
H& Mellen, Onun B. adam
Registered No.
47
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
white
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Merdow
6 DATE OF BIRTH
29
1862
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day ......... hrs.
00
yrs.
6
mos. 23
.ds.
or ........ min. ?
8 OCCUPATION
(a)' Trade, profession, or
particuler kind of work.
at home
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
James Mellen
PARENTS
12 MAIDEN NAME OF MOTHER Cynthia M. Barber
13 BIRTHPLACE
OF MOTHER
(State or country)
Boltout
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
MEadama
(Address) Chelettes Than
15 Filed July 23, 1913 Edward Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
(Month)
(Day)
.....
191.3
(Year)
17
I HEREBY CERTIFY that I attended deceased from
July 5th
.... ,
, 1913. to
July 21 et
1913
.....
that I last saw her alive on.
July 21et
191.3.
and that death occurred, on the date stated above, at 1.30 am-
The CAUSE OF DEATH* was as follows :
Typhoid From
(Duretion)
yrs.
mos.
17
„ds.
Contributory
(SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
....
amara toward
·
M.D.
Jah 22, 1913 (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
Hortatherton Chelong July 23 1913
20 UNDERTAKER Walter Perham
7 ADDRESS
Chelmsford
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
218 Chelmetra (City of town.)
In the
7
11 BIRTHPLACE OF FATHER (State or country) Richmond Ist.
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, Architeet, 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- mun, (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, Laborcr - Coal minc, 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 lias 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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