USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 34
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Statement of cause of death. - Name, first, the DIS- EASE 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; Broneho- pneumonia ("Pneumonia," unqualified, is indefinite) ; T'uber-
eulosis of lungs, meninges, peritonaeum, etc., Careinoma, Sar- coma, etc., of (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles; 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 .; 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," "Hacmorrhage," "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 ACCI- DENTAL, 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 carbolie acid - probably 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 provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing 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.
7 AGE PARENTS important. See instructions on back of certificate. 15 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
PLACE OF DEATH Chensford mark Sinith avenue
Bridget Smith
2 FULL NAME [If married or divorced woman or widoy : give maiden name, also name of husband.] .ªRESIDENCE
Bridget Milch, John J.
Smith avenue Chemsford
PERSONAL AND STATISTICAL PARTICULARS
.ª SEX A
1 4 COLOR OR RACE
Franale white
5 SINGLE,
MARRIED, Imarried
· WIDOWED,
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
(Month)
(Day)
-
(Year)
69
.yrs.
mos.
ds.
........ min. ?
8 OCCUPATION
Homework
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
at Home
9 BIRTHPLACE
(State or country)
Island.
10 NAME OF
FATHER
(unknown) Welch
11 BIRTHPLACE
OF FATHER
(State or country)
Iseland
sela
12 MAIDEN NAME
OF MOTHER
unpnou
own
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Adress) Chambord Centro
Filed. Self- 2 1913 Edward De Politie
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
Cinq 2, 1913, to
aug. 29
1913
that I last saw h .............
alive on ...
191
.. .
and that death occurred, on the date stated above, at ...
m.
The CAUSE OF DEATH* was as follows :
Entero colitis
(Duration)
.......... yrs.
mos.
ds.
myocarditis
.
Contributory.
(SECONDARY)
(Dustion) ..........
yrs,
mos. ds.
(Signed)
Chia 3093 (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. ......
19 PLACE OF BURNL OR REMOVAL
..
Valiches
DATE OF BURIAL
Towall Salut 2013
10 UNDERTAKER
ADDRESS
923
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
52
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
24
(Day)
1913.
(Year)
1
If LESS than
1 day. ....... hrs.
.......
M.D.
Ward)
;...
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never returu "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 Ilousewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be takeu 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," ete.), " 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.
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.
4
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Culus ford
(No Chewersford
Storaet laistois
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
lestora B. Valuestora
Registered No.
53
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
white
& SINGLE
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Depr ...
(Month)
(Day)
1913
(Year)
6 DATE OF BIRTH
Oct 2
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day .......... hrs.
11 yrs. 10
...... mos. .
6
ds.
or.
......
min. ?
-
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
Factura of Skull 0
(Duration)
.yrs.
mos.
ds.
9 BIRTHPLACE
(State or country)
Carlisle
Contributory
(SECONDARY)
(Duration)
rs.
Infos.
ds.
M.D.
(Signed)
5012 93
(Address).
Rowrel, Wars.
i LOO, 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.
In the
mos.
ds.
State
yrs.
.. mos.
ds.
13 BIRTHPLACE
OF MOTHER
(State or country)
newyork City
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
This Har Heald
(Address) Chelmsford
w.
15 Filed Seft 4 1913 Edward & Robbing
REGISTRAR
224 Chelmsford
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MARGIN RESERVED FOR BINDING
10 NAME OF
FATHER
Horam H. Heald
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Carlisle
12 MAIDEN NAME
OF MOTHER
Emma a. Chase
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Trestlawn Cem, Lowell
DATE OF BURIAL
Lepp 4
1913
CO UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
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).
27
1901
St. : Ward)
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, c. 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 linc 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," "Forcman," "Manager," "Dcaler," 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 Nonc.
Statement of cause of death. - Name, first, the DIS- EASE 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, peritonacum, ete., Carcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (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 discase can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septieacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, 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 - probably 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 provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing 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 io be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH 1 PLACE OF DEATH
Chelmsford wass
.(No
St. :
Ward)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
l'ale
4 COLOR OR RACE
White
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
....
(Month)
(Day)
..
(Year)
6 DATE OF BIRTH
June
26
1843
-
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day .......... hrs.
70
yrs. 2 mos. 8 .ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Carpenter
(b) Generai nature of industry. business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Dracut Mass
10 NAME OF
FATHER
Wm Austin
11 BIRTHPLACE
OF FATHER
(State or country)
Dracut Mass
12 MAIDEN NAME
OF MOTHER
Mary Smith
13 BIRTHPLACE
OF MOTHER
(State or country)
Beverly Mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
T Florence Austin
(Address) Chelmsford Mass
16 Filed Sett. 5. 1913 Edward Y. Robbins
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
191
........ , to ........
......
that I last saw how ... alive on
........
1
sekt 1.
.. 1913.
and that death occurred, on the date stated above, at .................... m.
The CAUSE OF DEATH* was as follows :
General arteriosclerosis
.... (Duration)
.............. yrs.
....... mos .............
... ds.
Contributory.
Cerebral hemorrhage?
(SECONDARY)
..... ,(Duration)„
yrs.
mos. ds.
(Signed)
....
M.D.
Sept. 4, 1913 (Address)
Chelmsford. Man.
* 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.
ds ..... ....... Where was disease contracted, If not at place of death ?...
Former or usual residence. ........
19 PLACE OF BURIAL OR REMOVAL Edson Cemetr.
DATE OF BURIAL
Sent 5, 1913
20 UNDERTAKER
young and Blake
ADDRESS
33 Prescottsx
MARGIN RESERVED FOR BINDING
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 .
225
.......
(City or town.)
'FULL NAME.
Charles H. Austin
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Cheinsfer' Centra
Registered No.
54
18 DATE OF DEATH
Sept 3 1913
191
sept.1.
.1913.
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) Forcman, (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 Ilousc- keepers who receive a definite salary), may be entered as Housewife, Hlousework, 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, peritondeum, etc , C'arcinoma, Sur- coma, etc., of .. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronic valvular heart disease ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," " Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," " PUERPERAL peritonitis," etc. State cause for which surgical 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 deuth 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.
@RESIDENCE
Chelmsford
3 SEX
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
Hemale
4 COLOR OR RACE
Mite
6 DATE OF BIRTH
Dec
(Month)
(Day)
7 AGE
8 OCCUPATION
at home
(a)' Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
PARENTS
(Informant)
7/5 Sargent
(Address)
electric
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
81
.yrs. ..
8
.mos. ...
10 ds.
9 BIRTHPLACE
(State or country)
Ho. Edgecomb, Mer
10 NAME OF
FATHER
Osborne Moore
11 BIRTHPLACE OF FATHER (State or country) Ho Edgecomb We.
12 MAIDEN NAME OF MOTHER Mary Sove
13 BIRTHPLACE
OF MOTHER
(State or country)
The Edgecomb, Me.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
16 Filed. Self. 5~ 1913 Edward . Rolfing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Left.
(Day)
(Month)
4
191 3.
(Year)
17 I HEREBY CERTIFY that / attended deceased from
191
..... , to
Sekt, 4
1913.
If LESS than
1 day,
.... hrs.
that I last saw
alive on
Left 4
1913
and that death occurred, on the date stated above, at 7:15 Pm
The CAUSE OF DEATH* was as follows :
Malignant Disease (Probably Car -
cenoura) of Activio and Rectum
.(Duration) ..
................ yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration)) .......... yrs.
mos. ds.
(Signed)
Sept. 25
....
Although. codon
.
M.D.
Chelmsford mass.
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.
In the
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 Smaland Mass
DATE OF BURIAL
1913
............
ADDRESS
20 UNDERTAKER
Tratten Perham
226 Chelmsford (City or town.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
'FULL NAME Sophia Sove Sargent
[If married or divorced woman or widow give maiden n S. S. Morre, Marren Sargent
Registered No.
55
PERSONAL AND STATISTICAL PARTICULARS
Nedoss
25 1831,
(Year)
or ........ min. ?
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford (No. Wildwood Ch Theattand St.
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 agc. 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 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.
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