USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 36
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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 fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid usc 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 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 (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," "Collapsc," "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.
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
I PLACE OF DEATH
Chelmsford Vas
.(No
St. :
......... Ward)
'FULL NAME.
Miriam H. Greenwood
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford Mass
miran permitey
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
8 6 DATE OF BIRTH
1844
(Month)
(Day)
I (Year)
7 AGE
if LESS than
1 day, ......... hrs.
... yrs .. .................. mos. . ......................
Or ......... min. ?
8 OCCUPATION
(e)' 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)
Engrand
10 NAME OF
FATHER
Samuel Fernley
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
England
12 MAIDEN NAME
OF MOTHER
Hannah
13 BIRTHPLACE
OF MOTHER
(State or country)
England
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Son
(Address)
Chelmsford Mass
18 Filed_ Sett. 26, 1913 Seward × 1211; .......
/
REGISTRAR
...
(Month)
(Day)
(Year)
HEREBY CERTIFY that I attended deceased from abilir, 1913 to Sept. 24
that I last saw her alive on Line IV, 1913 and that death occurred, on the date stated above, at.m. The CAUSE OF DEATH* was, as follows :
0
(Duration) L
....... yrs.
Contributory ...
(SECONDARY)
... (Duration) .......... yrs.
.............. mos.
. ................ ds.
(Signed)
M.D.
Sept 26/ 1913 (Address) 408 Tiddler en fr.
* 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.
. ...............
State ....
............ yrs. .
.......
ds.
Where was disease contracted,
if not at place of death ?...
Former or usual residence. ....
19 PLACE OF BURIAL OR REMOVAL Edson Cemetry
DATE OF BURIAL
Sent 27
191.
20 UNDERTAKER
Youngand Blake
ADDRESS
33 Quecorti.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
231
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Oleag Greenwood
Registered No. 60
10 DATE OF DEATH
Sent 24 1913.
191.
...
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- motivc 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 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- kecpers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employcd, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic 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 rc- 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 discasc; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease cansing 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 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.
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 North Quiches ford (No Middlesex V. Cor. Jay St
St. :
Ward)
Wallace a. Joscelyn
11
[If married or divoreed woman or widow give maiden name, also name of husband.] RESIDENCE Undaliser N. Cor. Yay 86. North Chale stord. mars
Registered No,
6/
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male Mite
& SINGLE
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
Midlinea
6 DATE OF BIRTH Sul and 1839 (Montlı)
(Day)
! (Year)
7 AGE
74 .
... yrs .. .... mos.
ds.
or ........ min. ?
8 OCCUPATION Parmiles
(a) Trade, profession, or particular kind of work.
(b) General nature of industry, business, or establishment in which employed (or employer) ..
(Duration)
yrs.
mos.
ds.
Contributory.
Cherrie Fabula Strach Arki
(SECONDARY)
.. (Duration):) ..
mos.
ds.
(Signed)
Thomas &Smith
M.D.
.. 1913
(Address).
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL OF HOMICIDAL.
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
col 4
1913
(Address) No Muchand
15 Filed Oct. 4, 1913 Edward S. Rolfing
REGISTRAR
16 DATE OF DEATH
(found dead)
Oal
1913
....
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased. The CAUSE OF DEATH* was as follows : Muminating Gas Poisoning rendutal
9 BIRTHPLACE (State or country)
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or country
12 MAIDEN NAME OF MOTHER Marie Chandler
13 BIRTHPLACE OF MOTHER (State or country)/
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
A& Gay.
232
(City or town.)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
20 UNDERTAKER (Wennbecht , acheter ADDRESS
2 FULL NAME
4 COLOR OR RACE
If LESS than 1 day, hrs.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- 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, Architeet, 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," ete., 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 domestie 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.
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 ferer (the only definite synonym is "Epidemie 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; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ete. State eause 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, cte.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
-
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Comumnonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
St. :
...... ... Ward)
minde
[If married or divorced woman or widow
give maiden name, alsø name of husband.]
@RESIDENCE
d'alex. Or Male le minin
Registered No.
62
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
8 SEX
Jamás Vilinte
4 COLOR OR RACE
5 SINGLE,
,
MARRIED
WIDOWED, France
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Cect: 4th 19130
(Month)
(Day)
(Year)
· DATE OF BIRTH
BIRTY Way Back 185.2
(Month)
(Day)
(Year)
7 AGE
61 . 6
mos.
If LESS than { day, ........ hrs.
28
ds.
Or ........ min. ?
cithine
The CAUSE OF DEATH* was as follows :
Cauces oy Geval-
.(Duration)
2
.... yrs.
...
mos.
ds.
Contributory ..
(SECONDARY)
(Duration)
... yrs.
mos.
ds.
(Signed)
JE Varmen
M.D.
.....
, 191 3 (Address)
21. Chila fers
* If death foilowed 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, notat place of death ?.
Former or usual residence ....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
(Address) V Mehrfach Dintbhelmywallet 7 93
20 UNDERTAKER
.....
REGISTRAR
233
(City or town.)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
1 PLACE OF DEATH? 2 FULL NAME & OCCUPATION (a) Trade, profession, o particular kind of work (b) General nature of industry, business, or establishment in which employed (or employer). 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (State or ente 12 MAIDEN NAME OF MOTHER PARENTS 13 BIRTHPLACE OF MOTHER (State or country) (Informant) CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ....... .... yrs.
9 BIRTHPLACE
(State or country)
Commence Mari
mar
Healer
Wahrefrelack
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE ,
16 File Oct. 7, 1913 Edward Y, Rottin,
ADDRESS
l. Nembeck Market
.......
17
I HEREBY CERTIFY that I attended deceased from
Cres 13
1913
....
........ ,
to
Del.4-
1913
that I last saw her alive on
Ocl. 4-
1913
and that death occurred, on the date stated above, at
...
........
In the
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.
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
W Chelmsford
.(No
Mor Canal
St. :
Ward)
234 W. Chelmsford .... (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Walter Smith
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Und Chelmsford Road
Registered No.
63
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
(Month)
(Day)
V
191.2.
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
If LESS than
I day .........
hrs.
The CAUSE OF DEATH* was as follows :
accidental Morning
(Pour Canal)
(Duration)
.. yrs.
mos.
ds.
(Duration)
yrs.
.mos.
ds.
JU Meris
J
M.D.
(Signed)
Www.5. 193
(Address).
160 thesmack 2
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).
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
Nov 10. 1913
20 UNDERTAKER
ADDRESS
Chelucford
3 SEX
4 COLOR OR RACE
white
Make
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month)
(Day)
7 AGE
... yrs.
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)
England
10 NAME OF
FATHER
Walter Smith
11 BIRTHPLACE
OF FATHER
(State or country)
England
12 MAIDEN NAME
OF MOTHER
May Rudking
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
England
(Informant)
Ser Billion
(Address)
M. Chelmsford
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
6
5 mos. 3
„mos. .
ds.
4
19.97
(Year)
........ min. ?
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
15
Filed
Nov. 10 ,1913 Edward J. Robban.
REGISTRAR
i
16 DATE OF DEATH
.
Contributory
(SECONDARY)
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 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 lino 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, wlio are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Ilousewife, Housework, or At home, and children, not gain- fully 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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