USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 35
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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 tho 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, 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 " (mercly symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," " Uracmia," " 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
important. See instructions on back of certificate.
PARENTS
12 MAIDEN NAME
OF MOTHER
Ellen J. O' Dowd
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Joseph D. Ryan Father
(Address)
N. Chelmsford, Mass,
16 Sept. 91, 3 Filed ....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Single
(Month)
(Day)
(Year)
« DATE OF BIRTH
October 28.
(Month)
190017
(Day)
(Year)
7 AGE
12
yrs. 10 mos. 9
ds.
Or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
School Boy
(b) General nature of industry, business, or establishment in which employed (or employer).
Student
9 BIRTHPLACE (State or country) N. Chelmsford
(Duration)
.yrs.
mos.
ds.
Contributory ..
Appendicitis
(SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
F. L. Gage
M.D.
Sept. 2, 93
( Address ).
Wyman's xxch.
* 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.
In the
...... ds ...
Where was disease contracted, If not at place of death ?.
Former or usual residence. .....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
St. Patrick's Cemeteryent. 993
. UNDERTAKER
ADDRESS
J. F. O' Donnell & Sons Lowell
227
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Lowell, Mass. (No. St. John's Hospital ... St. :
Ward)
NOV311
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Gerald J. Ryan
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Middlesex Street, N. Chelmsford, Mass.
,6
Registered No. 1232
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
September 6,
1913
I HEREBY CERTIFY that I attended deceased from
Sept. 2, . 193 to Sept. 6.
.. 191 3
If LESS than
I day ........
hrs.
that | last saw
1ml alive on Sept. 6.
1913
and that death occurred, on the date stated above, at 13on.
in.
The CAUSE OF DEATH* was as follows :
Peritonitis
10 NAME OF
FATHER
Joseph D. Ryan
11 BIRTHPLACE
OF FATHER
(State or country) Providence, R. I.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
1
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative hoalthfulness 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. Bnt in many casos, 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 minc, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receivo 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 whatover, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to tinie 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," nnqualified, 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," 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.
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 found dead opposite Chilius ford, Mas (No Riverside County
Eugene Vaillant
2 FULL NAME [If married or divorced wonfan or widow give maiden name, also nand of husband.] aRESIDENCE 325 forrest QUE, Jun avon. Fa
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male. White
5 SINGLE,
MARRIED,
WIDOWED Married.
OR DIVORCED
(Write the word)
16 DATE, OF DEATH
found dead
Sept
(Month)
(Day)
11
1919
(Year)
6 DATE OF BIRTH
Mais
11.
18.75.
(Year)
(Month)
(Day)
7 AGE
38
.yrs.
3
mos.
10
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Office Salesman
(b) General nature of industry,
business, or establishment in
which employed (or employer).
Office Salesman
9 BIRTHPLACE
(State or country)
Cleveland, O.
PARENTS
12 MAIDEN NAME
. OF MOTHER
Belle Campbell,
13 BIRTHPLACE
OF MOTHER
(State or country)
Ashland, O.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informan
Maurice & Vaillant
(Address)
116 Princeton 8%.
16
File Selt. 12, 1913 Edward J. Robbins
REGISTRAR
17
I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
you - shot would of Head-
Probathe Suicide .
....
.(Duration)
.yrs.
mos.
ds.
Contributory ... (SECONDARY)
Thousand Stwach.
..
M.D.
ds.
(Signed)
Sept ir, 1913 (Address).
Power Wall.
V accDO. 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
Lowell Cemetery Sept.
............
1913
20 UNDERTAKER
Gro Malealey.
· ADDRESS
79 Branch St.
228 No: Chelmsford. {Citr or towns Ward) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
St. :
. North Chuchusford-
Registered No.
57
4 COLOR OR RACE
If LESS than
I day ......... hrs.
10 NAME OF
FATHER
Maurice 6. Vaillant.
11 BIRTHPLACE
OF FATHER
(State or country)
Cleveland, O.
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 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 specifieation, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who arc engaged in the duties of the household only (not paid House- . keepers who receive a definite salary), may be entered as Housewife, Houscwork, 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 indieated thus: Farmer (retired, 6 yrs.). For persons who have no oecu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cercbro-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, Sur- coma, ete., of. ......... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, ctc. 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 merc symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ctc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age,"
"Shoek," "Uraemia," "Wcakness," 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. 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 rceognized 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
Chelmsford Centre Masso
St. ;..................... Ward)
[if death occurred In a hospital or institution, give its NAME Instead of street and number.]
2FULL NAME Usareff B. Smith [If married or divorced woman or widow give maiden name, also name of husband.] Usareff B. Chilton William A. Smith
@RESIDENCE
Chelmsford Mass
Registered No.
(58
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
8 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED, Married
WIDOWED,
OR DIVORCED
(Write the word)
1ª DATE OF DEATH
Sept 20 1913.
191
(Month)
(Day)
(Year)
S DATE OF BIRTH
March211846
(Month)
(Day)
..
(Year)
TAGE
If LESS than
I day .......... hrs.
Of ......... min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
At home
(b) General nature of industry, business, or establishment in which employed (or employer) .....
9 BIRTHPLACE
(State or country)
Clarenceville Canada
.(Duration).
mos. ds.
Contributory. (SECONDARY)
(Duration)
ds.
.... mos.
(Signed) Com
01. 2/01 3 (Address) 3224
* 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 ............ yra.
............ mos.
.......... ds ...........
Where was disease contracted, If not at place of death ?. ............
Former or usual residence.
.
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
William A. Smith
(Address) Chelmsford Mass
Filed_ Seft. 20, 1913 Edward ), Rolfing
REGISTRAR
19 PLACE OF BURIAL OR REMOVAL Colson Cemetery
DATE OF BURIAL
Sent 22
191
...... 1
20 UNDERTAKER C. in. young
ADDRESS
33 whencook
M.D.
11 BIRTHPLACE OF FATHER (State or country) Clarenceville Canada
4
PARENTS
12 MAIDEN NAME
OF MOTHER
Emeline Blodgett
18 BIRTHPLACE
OF MOTHER
(State or country)
Swanton Vt
229
...
67 yrs. 6 ....... mos. ds.
17 I HEREBY CERTIFY that I attended deceased from Cinq 12, 1913, to. Saft 2019/ 3 that I last saw h & alive on 10 af 9. 19,19/3 1 and that death occurred, on the date stated above, at 2 2m.
The CAUSE OF DEATH* was as follows : Conte nachit 12
.
-
....
10 NAME OF FATHER George C. Chilton
(City or town.)
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 single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Arehiteet, Loco- motive engineer, Civil engineer, Stationary fircman, 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 sccond 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; Broneho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
eulosis of lungs, meninges, peritonacum, ctc., Carcinoma, Sar- eoma, etc., of .. (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronic 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," " All- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," " Weakness," ctc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by 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.
=
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
important. See instructions on back of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH I PLACE OF DEATH
(No ) chkry Shirt
Forbud mosca l'assidy
2 FULL NAME. [If married or divorced woman or widow give maiden name, also name of husband, @RESIDENCE ripley Stuff gott Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
female white
4 COLOR OR RACE
-
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the words Ler's
· DATE OF BIRTH
7 AGE
If LESS than
1 day ......... hrs.
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).
9 BIRTHPLACE
(State or country)
20th Chehaving
PARENTS
11 BIRTHPLACE OF FATHER (State or country) 1
Ausland
12 MAIDEN NAME OF MOTHER March of Honan
18 BIRTHPLACE OF MOTHER (State or country) Aucland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) hus Laugh Cassidy brother
(Address)
15 Filed Sept. 21 /1913 /edward, Robbins
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from 3 Salt-1, 1913, to Juff-21 191
7
........ . that I last saw har alive on Soft. 20 1913. ... and that death occurred, on the date stated above, at .................. m. The CAUSE OF DEATH* was as follows :
-
1
.. (Duration)
.......
.. yrs. .....
.... mos.
ds.
Contributory. (SECONDARY)
(Duration)
....
.yrs.
.mos.
... ds.
(Signed)
7 E Varney
M.D.
f1 22, 1913 (Address) A. Chiliasfind
....
* 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
DATE OF BURIAL
3
191 0
20 UNDERTAKER
ADDRESS
230
(City or town.)
St. : Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
59
=
16 DATE OF DEATH
Sift.
21
191 3
V (Month)
(Day)
(Year)
-
...
(Year)
(Month)
(Day)
4.
mos.
.ds.
.. yrs.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
10 NAME OF
FATHER
Patrick Cassidy
....
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 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 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 DEATII, 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 Nonc.
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