USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 38
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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 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 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 .; Broucho-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.
3. Sudden deaths of persons not disabled by recognized disease, as A death upou the street, or ouc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dcad, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX Female 7 AGE PARENTS important. See instructions on back of certificate. N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ....
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford (No
St. : Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2FULL NAME Christina arvedson
[If married or divorced woman or widow give maiden name, also name of husband.] Care a arvedion.
@RESIDENCE
Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Widow
6 DATE OF BIRTH
V 1850
.....
(Month)
(Day)
(Year)
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)
Sweeden
10 NAME OF
FATHER
11 BIRTHPLACE OF FATHER (State or country) Sweeden
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
Sweden
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
N. Hannaford
(Address)
Chelmsford
15 Filed Dec. 14, 1918 Edward JobJobbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17 I HEREBY CERTIFY that I attended deceased from Nov. 23, 1913, to DEC 10. 1913
If LESS than
I day ...
.. hrs.
that I last saw her alive on.
1913
and that death occurred, on the dato stated above, at
m.
The CAUSE OF DEATH* was as follows :
Myocarditis
abthisis Pulmonalis
....
Probable, more than 2 years
.. (Duration) ...
..........
... yrs.
Contributory ..
(SECONDARY)
(Duration) ...
......
Autrung, Scolaria
mos.
ds.
M.D.
.... yrs.
(Signed)
Dic.13.
,1913. (Address)
Chelmsford Verras,
* 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 ..
12 PLACE OF BURIAL OR REMOVAL Next Cemetery
DATE OF BURIAL
DEC14 1913
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
(Day)
10
19| 3.
(Year)
63
yrs.
mos.
5
ds.
or ........ min. ?
239 Chelmsford (City of towu.)
Registered No.
68
(Month)
amos.
ds.
.
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, Loeo- motive engineer, Civil engineer, Stationary fireman, ctc. 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 au 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," "Forcmau," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coal mine, etc. Women at home, who are engaged iu 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.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to tiure 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 pueumonia ") ; Lobar pneumonia ; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tubcr-
culosis of lungs, meninges, peritonacum, etc., C'arcinoma, Sar- coma, etc., of. ...... ....... (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignaut ueoplasms) ; 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," "Hemorrhage," " Iuanition," " 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 septieuemia," " 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 couditions 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 Chelmsford (No
Merrill Uvodward
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Tynastavo Read, Chelmsford Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
viale white
4 COLOR OR RACE
6 SINGLE
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
Sigle
6 DATE OF BIRTH let 21 (Month)
(Day)
1906
1
(Year)
7 AGE
If LESS than I day ......... hrs.
9
yrs.
mos.
ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
None
(b) General nature of industry, business, or establishment in - which employed (or employer) ..
9 BIRTHPLACE
(State or country)
" Breton Mars
PARENTS
11 BIRTHPLACE OF FATHER (State or country) " Bangar Que
12 MAIDEN NAME OF MOTHER Catherine Walsh
13 BIRTHPLACE OF MOTHER (State or country)
tilland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
dive Woodward
16
Filed .. Dec. 22 1913 Ederand fi Robbing _REGISTRAR
17 I HEREBY CERTIFY that I have investigated the death of the deceased. The CAUSE OF DEATH* was as follows : Uccidel (Struck by automobile)
(Duration) ............. yrs. ds.
Contributory ..
Conforme Fracture
.....
mos.
(SECONDARY)
.. ds.
(Signed)
DEc. 22, 1913
(Address) ....
160 Reaswack
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, OF RECENT RESIDENTS).
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
(Address) No Chelmsford North Chel un dee Dee 24 1919
CO UNDERTAKER
STRA Act Wembrech 16 machet
ADDRESS
Ward)
240 Chelmsford ... (City or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
69
16 DATE OF DEATH
Die 21
1913
(Year)
(Month)
(Day)
10 NAME OF
FATHER
Otiz Werdward
M.D
In the
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oceu- pation is very important, so that the relative healthfulness of various pursuits ean 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 fireman, ete. But in many cases, espceially 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) Groccry; (a) Foreman, (b) Automobile factory. The material worked on may form part of the sceond statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal minc, ete. Women at home, who are engaged in the duties of the household only (not paid House- keepers who reecive 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 serviec 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 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 causation), using always the same accepted term for the same diseasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, is indefinite) ; Tuber-
eulosis of lungs, meninges, peritonacum, etc., Careinoma, Sar- eoma, cte., of. .(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronie valvular heart discase; Chronic interstitial nephritis, ete. The contributory (second- ary or intereurrent) affection need not be stated unless im- portant. Example: Measles (disease eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report incre symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shoek," "Uraemia," "Weakness," ctc., 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," cte. Statc eausc 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 fraeture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."
1
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, Homieidc, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX 7, 7 AGE 50 (b) General nature of industry, business, or establishment in which employed (or employer). PARENTS important. See instructions on back of certificate. (Address) 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 .. yrs.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford Mars (No.
Littleton Road
St. :
Ward)
(City or yown.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Sarah Elizabeth Balser
2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford.
Widow of aaron Balsu
... ...
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
Nov. 28
.. 1913
Drc. 21
191
..... .
.. , to
that I last saw her. alive on.
DEC 21, 1913.
arbut 51pm.
and that death occurred, on the dato stated above, at .....
The CAUSE OF DEATH* was as follows : Myocarditis Cerebral hermanhogy Senility
.(Duration)
.. yrs.
mos.
ds.
Contributory
(SECONDARY)
(Signed)
Antrung Scoloria
.(Duration)
.........
... yrs. .
mos.
ds.
M.D.
Orc. 22
1. 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
In the
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
Cem.
Unnapolis to. N. S.
DATE OF BURIAL
Klec. 24 1913
.....
15 Filed Dec. 22 1918 Edward . Rolling ............
REGISTRAR
chelmsford
Registered No.
70
+ COLOR OR RACE
w
5 SINGLE,
MARRIED,
WIDOWED, Widowed
OR DIVORCED
(Write the word)
G DATE OF BIRTH
May
(Month)
(Day)
1833
(Year)
If LESS than
[ day, ....... hrs.
mos.
ds.
or ........ min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
at home
9 BIRTHPLACE
(State or country)
Nova Scotia
10 NAME OF
annapolic les.
FATHER
William armstrong
11 BIRTHPLACE
OF FATHER
(State or country)
Nova Scotia
12 MAIDEN NAME
OF MOTHER
Mary a millbury
13 BIRTHPLACE
OF MOTHER
(State or country)
Nova Scotia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. le. Nickolas
24h
3.
(Month)
(Day)
(Year)
20 UNDERTAKER
Walter Tenham Chelmsford, Mal.
ADDRESS
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oeeupa- tion is very important, so that the relative healthfulness of various pursuits ean 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, Loeo- motive engineer, Civil engineer, Stationary fireman, ete. 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," ete., without more precise specifieation, as Day laborer, Farm laborcr, Laborer - Coal mine, ete. 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, ete. 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 faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oeeupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE 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 "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, peritonaeum, ete., Carcinoma, Sar- coma, ete., of. (name origin: "Caneer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. 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," ete., when a definite disease can be aseertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," ete. 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.
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
No Chelmsford Mass
.(No.
St. : ................ Ward)
"FULL NAME Devil M . Knox
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
No Chelmsford Mass
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Tale
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED, Single
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Dec 21 1913
(Month)
(Day)
191
( Year)
& DATE OF BIRTH
7832
-
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day, ......... hrs.
31
.. yrs. 10 .mos. 17
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)
Scotland
not Known ling durchen (Duration) .......... y's. ............... mos. ds.
Contributory ..
(SECONDARY)
.(Duration).
............... yrs.
mos.
ds.
(Signed)
72 Varer
M.D.
...* I
Rec 22 1913 (Address) nickelatferd.
* 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 ....
.ds ...
Where was disease contracted,
if not at place of death ?....
Former or
usual residence.
1º PLACE OF BURIAL OR REMOVAL
Riverside Cemetry
No Chelmsford Mass
DATE OF BURIAL
Dec 23
191.
(Address) No Chelmsford M:
Filed. Dec. 23. 1913 Edward Je Parking .......
REGISTRAR
242
....
......... (City or town.)
[If death occurred ix a hospital or institution, give ita NAME instead of street and number.]
Registered No.
7
.... .........
17
I HEREBY CERTIFY that I attended deceased from
Dec 14
, 1913 to Dee 21, 1913
that I last saw h ___...... alive on.
Dec- 20
1913.
and that death occurred, on the date stated above, at 6 am.
The CAUSE OF DEATH* was as follows :
Epilepsy
10 NAME OF
FATHER
James Knox
PARENTS“
11 BIRTHPLACE
' OF FATHER
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
Annie Mc Naughton
18 BIRTHPLACE
OF MOTHER
(State or country)
Scotland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Tennia Unor
..........
20 UNDERTAKER
ADDRESS
330 Piecistraff
MARGIN RESERVED FOR BINDING
-
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 cxamples: (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 Housc- kcepers 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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