USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 37
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39
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-
culosis of lungs, meninges, peritonaeum, etc., Careinoma, Sar- eoma, ctc., 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 .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head-homicide ; Poisoned by carbolic acid - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden 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.
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 Chelmsford Gente w.
stawo ald Barton Roadsty
00
Michel Deboeuf
'FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.1
)
@RESIDENCE
Chelmsford Center
Registered No.
64
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Vote the word)
1ª DATE OF DEATH
Nar 1.4
(Month)
(Day)
1913
(Year)
6 DATE OF BIRTH
Qua
(Month)
18
(Day)
18/19 (Year)
7 AGE
If LESS than
1 day ......... hrs.
54 yrs. 2 mos. 27 da.
or ......... min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
Harrer
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Ganada
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Gommada
12 MAIDEN NAME
OF MOTHER,
IMane
Brodeur
18 BIRTHPLACE
OF MOTHER
(State or country)
Ganiada
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16 Filed 201. 17, 1913 Edward fo Robbery
REGISTRAR
- 1
that I last saw homme alive on.
Nur. 14
1913
and that death occurred, on the date stated above, at ..... m.
The CAUSE OF DEATH* was as follows :
Disease of Liver Probably
maria naux-
1x8 monaten
(Duration) ...............
... yrs.
.mos.
ds.
Contributory .. (SECONDARY)
(Duration) ...
.............. yrs.
.mos.
ds
(Signed)
Actu S. Scoloria
M.D.
210014 93 (Address) Chuchus fordi Mars.
* 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.
............. 08.
ds
Where was disease contracted, if not at place of death ?..
Former or usual residence .......
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
20 UNDERTAKER
ADDRESS
738
(City or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
Ward)
235
MARGIN RESERVED FOR BINDING
10 NAME OF
alepanche Leboeuf
I HEREBY CERTIFY that I attended deceased from
apr. 29
.1913 to.
Nov. 14, 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) 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 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 samo disease. Examples: " Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port "Typhoid pneumonia") ; Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. ..... (name origin: "Cancer" is less definite ; avoid use of "Tumor " for malignant neoplasms) ; Measles ; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," "An- aemia " (merely symptomatic), " Atrophy," "Collapse," " Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," " Haemorrhage," "Inanition," " Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
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.
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
I PLACE OF DEATH
Lowell, Mass. (No. Lowell General Hospital St. ;...
....... .Ward)
Lowell (City or town.) fif death occurred in a hospital or institution, give its NAME Instead of street and number.]
2FULL NAME
Marion Nolan Yeomans
[If married or divorced woman or widow give maiden name, also name of husband.]
Marion Nolan
Edward S. Yeomans
Registered No.
1572
@RESIDENCE
Newfield St., N. Chelmsford, Mass.
MEDICAL CERTIFICATE OF DEATH
3
191
(Year)
6 DATE OF BIRTH
October 12,
1867
(Month)
(Day)
1 (Year)
46 ...:
yrs .:....
1
..... mos.
.... ds.
10
or ....... min. ?
17
I HEREBY CERTIFY that I attended deceased from
Nov. 20
1913 to
Nov. 22.
193
that I last saw h .... @T alive on Nov. 22.
1913
and that death occurred, on the date stated above, at& P. m.
The CAUSE OF DEATH* was as follows :
Cerebral Embolism
......
9 BIRTHPLACE
(State or country)
Canada, P. G.
10 NAME OF
FATHER
William Nolan
11 BIRTHPLACE
OF FATHER
(State or country)
Canada
12 MAIDEN NAME
OF MOTHER
Mary
-
18 BIRTHPLACE
OF MOTHER
(State or country)
Canada
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(informant)
Edward S. Yeomans
(Address)
N. Chelmsford, Mass.
Nov. 28, 1913. Filed.
191
---
REGISTRAR
(Duration).
1-2 hour
ds.
Contributory ...
Double Salpingectomy
(SECONDARY)
(Duration)
............... yrs.
mos.
ds
(Signed)
F. L. Gage
M.D.
Nov. 24. 2917( Address).
Lowell, Mass.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
... yrs.
.mos.
. ................
State ....
In the
Where was disease contracted, if not at place of death ?.
Former or usual residence.
PLACE OF BURIAL OR REMOVAL Riverside Cemetery. N. Chelmsford, Mass.
DATE OF BURIAL
Nov. 25,1913
· UNDERTAKER Vm H. Saunders
ADDRESS
12 Hurd St.
MARGIN RESERVED FOR BINDING
8 SEX
Female
TAGE
8 OCCUPATION
PARENTS
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
....
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Married
(Month)
(Day)
... :
If LESS than
I day ......... hrs.
(a)' Trade, profession, or
At Home
particular kind of work
(b) General nature of industry.
business, or' establishment in
' which employed (or employer).
10 DATE OF DEATH
November 22,
65
PERSONAL AND STATISTICAL PARTICULARS
236
2
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 agc. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engincer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional 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, Laborcr - Coal minc, etc. Women at home, who are engaged in the duties of the household only (not paid House- kccpers 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 homc. 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.
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 diseasc. 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- 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 necd not be stated unless im- portant. Example: Mcaslcs (disease causing death), 29 ds .; Broneho-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 agc," "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 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.
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 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.
1 6
Filed Dec. 2 1913 Edward S. Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE
white
5 SINGLE
MARRIED
married
WIDOWED,
OR DIVORCED
( Write the word)
16 DATE OF DEATH
nor
30
1913
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Oct-23, 1953, to
Marzo
1913
..... .
that I last saw him alive on.
Mer 29
193
and that death occurred, on the date stated above, at 3 9m.
The CAUSE OF DEATH* was as follows :
Carcinoma of stomach
.(Duration) .
yrs.
6
mos.
ds.
Contributory
(SECONDARY)
(Duration)
......
.... yrs.
mos.
ds.
JE Varney
M.D.
1913 (Address).
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
In the
mos.
ds.
State.
.... yrs.
.mos.
ds
Where was disease contracted, If not at place of death ?
Former or usual residence ..
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
I.6. Marshall
......
(Address)
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Next Chelmsford
St. :
237 Cheliosford Ward) (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
66
PERSONAL AND STATISTICAL PARTICULARS
6 DATE OF BIRTH
(Month)
11
1839
(Day)
(Year)
7 AGE 74
If LESS than
1 day, .......
hrs.
yrs.
1 mos. 19
ds.
or ........ min. ?
8 OCCUPATION
(a): Trade, profession, or
particular kind of work
Retired /merchant)
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Bangor Me,
10 NAME OF
FATHER
Josiah E. Marshall
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Belfort, Ireland
12 MAIDEN NAME
OF MOTHER
Maria Hastings
13 BIRTHPLACE
OF MOTHER
(State or country)
marine
19 PLACE OF BURIAL OR REMOVAL Mast Cemetery
DATE OF BURIAL
Dec 2
1913
....
20 UNDERTAKER
Walter Perhave
ADDRESS
Chelmsford
Joseph Marshall 2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Met Chelmsford
MARGIN RESERVED FOR BINDING
(Signed)
Dec 19
.. ,
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, Architect, Łoco- 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, 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 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 ") ; Łobar 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 symptomatic), "Atrophy," "Collapse," "Coma," " Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examinors :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. 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
23,8 Chichesford
St. :
Ward)
(City or town.) [If deathloccurred in a hospital or institution, give its NAME instead of street and number.]
(Still born) Stiles
Registered No.
67
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
20
19[ $
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Dac 7, 1918, to
........ ,
191-
....
If LESS than
I day ...
hrs.
that I last saw h - alive on
...
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Stell-bow
(Duration)
yrs.
.mos.
ds.
Contributory
(SECONDARY)
(Duration)
.........
.... yrs.
mos.
ds.
(Signed)
alpy le Strument
M.D.
Ru. 18, 1913. (Address) 408 Middlesenkt.
* 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.
. ............. as .............
Where was disease contracted,
If not at place of death ?..
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Live Didge Cem alec. 8 191 3
ADDRESS
20 UNDERTAKER
Walter Serham Chelmsford
1 PLACE OF DEATH
Chelmsford (No
2FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
levelsfind
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Single
W.
5 SINGLE
MARRIED.
WIDOWED
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Dec.
(Month)
(Dây)
7 AGE
8 OCCUPATION
(a) Trade, profession, or
particuler kind of work.
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
W. B. Stiles
11 BIRTHPLACE
OF FATHER
(State or country)
Brocton
12 MAIDEN NAME
OF MOTHER
Raccindals valley
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
Nova Scotial
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
W.B. Stiles
important. See instructions on back of certificate.
(Address)
Clichnsfind
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
0
yrs.
0
mos.
0
ds.
or ........ min. ?
1913
(Year)
15 Filed Dec. 8 198 Edward . Rolling
REGISTRAR
....
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 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 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- inan, (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.
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.