USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 33
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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 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-
eulosis of lungs, meninges, peritondeum, etc., C'arcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasmns) ; 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 .; Broneho-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," "Uraenria," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX Female 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 Massarlutsetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
E. Chelmsford (No. .Mas.s. St. : Ward)
'FULL NAME
Petronelle
Tongking
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Olans Tongberg -- Petronelle Tingleholm E Chelmsford.
Registered No. 48
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
July 26
3
191
........
(Month)
(Day)
(Year)
6 DATE OF BIRTH
May
2.0
0.8.3137 (Year)
If LESS than
{ day ......... hrs.
80 .yrs. 2 ......
mos. 6 .ds. or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
At H me
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
********
9 BIRTHPLACE
(State or country)
Sweden
10 NAME OF
FATHER
Nichols Tingleholm
11 BIRTHPLACE OF FATHER (State or country) Sweden
12 MAIDEN NAME OF MOTHER
Helen ----
13 BIRTHPLACE
OF MOTHER
(State or country)
Sweden
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .... Mrs. Hilma Nelson
(Address)
E. Chelmsford Mass.
16 Filed. July 28, 1913 Edward Y, Nothing
REGISTRAR
...
.....
....
I HEREBY CERTIFY thay I attended deceased from
June 1, 1913 to.
July 26
191
that I last saw h 22 alive on ..
Ugull 20
1913
and that death occurred, on the dato stated above, at.
The CAUSE OF DEATH* was as follows :
Arteriosclerosis
....
.(Duration)
... yrs.
Co
.......
mos.
ds.
Contributory ... (SECONDARY)
L. J. Welch ,
(Signed)
Jul 26 6 3
(Address) 2/ Runels Beda
(* 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 ..
19 PLACE OF BURIAL OR REMOVAL Edson Cemetery
DATE OF BURIAL
July 28
1913
20 UNDERTAKER
WH Saunders
ADDRESS
12 Hurd St
219
Lowell ....
(City or town.) fif death occurred in a hospital or institution, give its NAME instead of street and number.]
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED, Widowed
OR DIVORCED
(Write the word)
(Month)
(Day)
3
....
1
.. (Deration)
mos.
ds.
......
.... M.D.
......
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.
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
(No Wright
St. :
.Ward)
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Wright St., No. Chelmsford.
Registered No.
49
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE
White
5 SINGLE
MARRIED.
Single
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
gula
0
(Month)
27. 191.13
(Day)
(Year)
6 DATE OF BIRTH July 0 (Monthy
16
(Day)
1913
(Year)
7 AGE
If LESS than I day ......... hrs.
Mos. 11 ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
none
(b) General nature of industry, business, or establishment In which employed (or employer) ....
none
9 BIRTHPLACE
(State or country)
North Chelmsford.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Eng. Chan. Il
12 MAIDEN NAME
OF MOTHER
Lois arpinwall.
18 BIRTHPLACE
OF MOTHER
(State or country)
mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Elien F. De La Haye Jr.
(Address)
north Chelmsford
15
Filed Sarkas 28, 1913 Edward X Potting
....
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
191
........ ,
to
Sale 27, 1913
...... .
that I last saw halive on
....
19| 3
and that death occurred, on the date stated above, at $ 30Pm.
The CAUSE OF DEATH* was as follows :
Infantile Convulsiones
2 hours
.(Duration)
...... yrs. ................ mos.
. ......
.. ds.
Contributory ...
(SECONDARY)
.. (Duration)
............... yrs.
.mos.
ds.
......
(Signed)
JE Varney
M.D.
July 28, 1913 (Address).
........
H. Chellenfel.
* 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
In the
of death,
.. yrs.
mos.
ds.
State ...
............ yrs.
............ rnos. ds ............. Where was disease contracted, if not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL Mare.
Riverside
north Chelms
DATE OF BURIAL
une ford July 28, 1913
20 UNDERTAKER
George W. Healey
ADDRESS
179 Branch St.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
2 FULL NAME
Elias Francia De La Hoya 3rd
220 No. Chelmsford HOity or toysn.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
....
....
.yrs.
10 NAME OF
FATHER
Elias F. De La Haya fr.
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 ('AUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. (name origin : "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy,""Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
...
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No. 5
PERSONAL AND STATISTICAL PARTICULARS
1 PLACE OF DEATH
Chelmsford Mass
(No ..
2FULL NAME.
Amasa H. Smith
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford Mass
3 SEX
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Male
6 DATE OF BIRTH
April 4 1848
(Month)
(Day)
7 AGE
$ 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)
Manchester N.H.
10 NAME OF
FATHER
Amasa Smith
11 BIRTHPLACE
OF FATHER
Unknown
(State or country)
12 MAIDEN NAME
OF MOTHER
Finance Clark
PARENTS
13 BIRTHPLACE
OF MOTHER
Unknown
(State or country)
(Informant).
Mrs A. H. Smith
(Address)
Chelmsford Mass
important. See instructions on back of certificate.
16
N. B .- Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
.6.5.
... yrs ...
4
.... mos ....
9
........... ds.
MEDICAL CERTIFICATE OF DEATH
1ª DATE OF DEATH
Aug 13 1913
191
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from July 27 1913 Una.
4. 13, 1913 that I last saw ha alive on Cang 13 and that death occurred, on the date stated above, at, 4Jam. The CAUSE OF DEATH* was as follows : Locomotor
about
2
(Duration)
mos. ds.
....... yrs.
Contributory ..
(SECONDARY)
.. (Duraon) ............ yrs. .....
.......... mos.
.............
ds.
(Signed)
M.D.
au. 13, 1913 (Adress) Chilenafood, Mais.
* 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.
mos.
Where was disease contracted, If not at place of death ?.
Former or usual residence .............
19 PLACE OF BURIAL OR REMOVAL Edson Cm. Lewall
DATE OF BURIAL
ang. 15
1913.
20 UNDERTAKER
ADDRESS
File ana 13, 1913 Edvard S. Robbing
.....
1 REGISTRAR
1
-
(Year)
If LESS than
& day .......... hrs.
or ......... min. ?
Post Office Click
Married
...............
St. ;................. .... Ward)
221
........ -
....
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
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 agc. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, 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 houschold only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully cmploycd, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Hlousemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affectlon 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 usc of "Croup") ; Typhoid fever (never re- port]," Typhoid "pneumonia") ; Lobar pneumonia; Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
eulosis of lungs, meninges, peritonacum, etc., Careinoma, Sar- eoma, etc., of .. .. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronie valvular heart disease; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " A11- 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 septieaemia," " PUERPERAL peritonitis," ctc. 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 deathis 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH No Cleverfood Kers. (No.
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Sarale I Small
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband ..
@RESIDENCE
fay
St- to. Chelen Ford
Sarah I. Paige Everett H. Small.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female. White
& SINGLE
MARRIED,
Married,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Jan.
(Montho
23.
(Day)
18:52
(Year) «
7 AGE
61 jrs. 6
.yrs.
If LESS than [ day ......... hrs.
mos.
26
ds .
or ....... min. ?
At Home.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
At Home
9 BIRTHPLACE
(State or country)
Mass.
Contributory
(SECONDARY)-
(Duration)
mos. ds.
M.D.
(Address).
Lowrat, lars-
Exige, 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.
mos.
ds.
Where was dlsease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL werde Cemetery No. Chelmsford, Mark.
DATE OF BURIAL
Aug- 20, 198
(Address)
No. Chelmsford
16 Filed any. 18, 1913 Edward S. Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH .
(Mónth)
(Day)
193
(Year)
I HEREBY CERTIFY that I have investigated the . death of the deceased.
The CAUSE OF DEATH* was as follows :
.
Индша
C
.
(Duration).
... yrs.
mos.
ds.
10 NAME OF
FATHER
- Paige.
11 BIRTHPLACE
OF FATHER
(State or country)
Mare.
12 MAIDEN NAME
OF MOTHER
Saphonia Barkin
Jakhroma.
13 BIRTHPLACE
OF MOTHER
(State or country)
Mars.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Inform
Everett ASmall
·
50 UNDERTAKER
Grof. Healey.
ADDRESS
79 Branch St.
8 OCCUPATION 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 particular kind of work
222 No. Chelmsford (City onto
Registered No. 51
4 COLOR OR RACE
18
17
(a) Trade, profession, or
(Signed)
linea 18
19×3
In the
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation 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, Architeet, 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 i 3 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. 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 occu- pation whatever, write None.
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