USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 39
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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 fevcr (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, 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.
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.
2
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
$ SEX PAGE 8 OCCUPATION 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 ....
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
East Chefnastod (No
Ford (No.
Elvira atwood
2FULL NAME
[If married or divorced woman or widow.
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford
lever, stenge Wastoviel.
Registered No.
72
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
Female White
1
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED volume
(Write the word)
16 DATE OF DEATH
December 22
1913
(Month)
(Day)
(Year)
· DATE OF BIRTH
fare 17
1832
1
(Month)
(Day)
(Year)
If LESS than
1 day ......... hrs.
81 yrs. 6.
1
.mos.
ds.
......... min. ?
(a) Trade, profession, or
particular kind of work ...
ifthat
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE (State or country) Mitment ON H
Nathiel
FATHER Wathiel Bleuse
11 BIRTHPLACE OF FATHER (State or country) 7 Salem UN
12 MAIDEN NAME
OF MOTHER
Betres Greeley,
13 BIRTHPLACE
OF MOTHER
(State or countrys
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant fcc
15 Filed. Dec. 24, 1913 Edward / Robbins .........
REGISTRAR
.. (Duration)
............. yrs ..
.......
.. mos. ....
......
ds.
Contributory ........
(SECONDARY)
-
1
.. mos.
................ ds.
a-E- Shar
M.D.
Jack 1943 (Address).
137 black.
.....
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
.yrs.
In the
mos. ........
ds.
State ....
............ yrs.
.......
mos.
ds
Where was disease contracted, if not at place of death ?..
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Parter Place WAX
DATE OF BURIAL
De@ 24.
1913
.......
ADDRESS
20 UNDERTAKER Hahm a Wennbeck
243
...
(City or town.)
St. ;................... .. Ward)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
MEDICAL CERTIFICATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
Dec 18 93
to.
2.2.22. 193
that I last saw her alive on. Due -21, 1913 and that death occurred, on the date stated above, at 3am. The CAUSE OF DEATH* was as follows :
.
......
....
(Duration)6
.... yrs.
.......
(Signed)
...
.........
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- molive 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. Tlic 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 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 (rctircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Namc, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Ccrebro-spinal fever (thie 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," 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) ; Mcaslcs; 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 (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ctc.), "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 scpticacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
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, 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 strect, or onc supposed to be due to Alcoholism, etc
4. Deaths under circumstances unknown, as A person found dcad, 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
11 BIRTHPLACE · OF FATHER (State or country) Lemple N. H.
12 MAIDEN NAME
OF MOTHER
Lizzie Courant
13 BIRTHPLACE
OF MOTHER
(State or country)
Lowell, Mars.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
7. W. Derghyshine
(Address)
Filedos Dec 28, 1913 Sevon collin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Whale
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Jungle
16 DATE OF BIRTH
Llec
27
(Month)
(Day)
1
(Year)
7 AGE
0 yrs. :C mos. 0 .ds.
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).
If LESS than
1 day, ..
hrs.
that I last saw h ...
alive on
191
...
and that death occurred, on the dato stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Stillborn
(Duration) ..
.. yrs.
mos.
ds.
Contributory.
(SECONDARY)
mos.
ds.
(Signed)
.. (Duration)
Antwan G Scolonia
.......
.yrs.
M.D.
DEC. 28, 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 residonce .. ......
19 PLACE OF BURIAL OR REMOVAL
Panele Cem.
20 UNDERTAKER Walter Pecham
ADDRESS
chelunsford
Mais.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford
(No
Golden Come Rd.
St. :
....
Ward)
Still Low Leurbychice.
2FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Cheles ford
PERSONAL AND STATISTICAL PARTICULARS
244 Chelmsford. (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
73
16 DATE OF DEATH
Dec 27
(Month)
(Day)
191 3
(Year)
17
I HEREBY CERTIFY that I attended deceased from
She 27, 1913, to.
0227 93
9 BIRTHPLACE
(State or country)
Chelmsford Mass
10 NAME OF
FATHER
7. W. Huilegaline.
....
.....
DATE OF BURIAL
Llec. 2.8 1913
1 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, 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, 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, peritoneum, etc., Carcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasmns) ; 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 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,
1 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 strcet, 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 Female 6 DATE OF BIRTH 7 AGE 8 OCCUPATION 9 BIRTHPLACE (State or country) 10 NAME OF FATHER PARENTS important. See instructions on back of certificate. (Address) 16 Filed. Dec 29 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 particular kind of work
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
#G Blossom
St. :
...
Ward)
WORCESTER (City or town.) [If death occurred in a hospital or institution, give its NAME instead of streat and number.]
2FULL NAME Sarah T. (Walton) Park [If married or divorced woman or widow give maiden name, also name of husband.] Widow of Andrew H Park
@RESIDENCE
Chelmsford, Mass
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec 27
1913
·
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Nov 24
.191 ...... 3 to
Dec 27
1913
...
that I last saw h .... @.J? alive on
1913
and that death occurred, on the date stated above, at ..... 5.30₽
The CAUSE OF DEATH* was as follows :
Cirrhosis of Liver
(Duration) .
........
1 yrs.
mos.
ds.
Contributory Hemorrhare
..........
(SECONDARY)
.(Duration)
yrs.
mos.
rds.
(Signed) Clarence N Whitaker
M.D.
Dec 28 . 1913 (Address).
Worcester
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
... )
yrs.
. mos.
ds.
State
... yrs.
In the
.mos.
.. ds.
Where was disease contracted, if not at place of death ?
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
Chefrisford Com
DATE OF BURIAL
Dec 28. 1913
Worcester
1
"0"ZREGISTRAR
:
(Month)
(Day)
(Year)
If LESS than
1 day, ....... hrs.
30
.yrs.
1 0mos.
nos.
7 ds.
or ......... min. ?
(a) Trade, profession, or
At home
(b) General nature of industry, business, or establishment in which employed (or employer) ...
So Redding, Mass
Jonathan Walton
Il BIRTHPLACE OF FATHER (State or country)
So Redding, Mass
12 MAIDEN NAME OF MOTHER Sarah Rugg
13 BIRTHPLACE
OF MOTHER
(State or country)
Lancaster, Mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(informant)
Sister
245
Registered No.
74
4 COLOR OR RACE
15 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Vidored
-
20 UNDERTAKEEssions Sons Co
ADDRESSester
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 singlo 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, 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 Ilouse- keepers who receive a definite salary), may be entered as Ilousewife, Housework, or At home, and children, not gain- fully employod, 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, Ilousemaid, 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 samo 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 (nover re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- eoma, 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," "Hacmorrhage," "Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
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.
1913. 1845. 68
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. Lowell
St. :
Ward)
2.4.6 Chelmann (or town.) For [If death occurred In a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Elmira E Sanford
[If married or divorced woman or widow give maiden n @RESIDENCE Lowell Road, Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female White.
4 COLOR OR RACE
L' SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
(Monthy
(Day)
(Year)
If LESS than 1 day ......... hrs.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Nome
(b) General nature of industry,
business, or establishment in
which employed (or employer).
At Home.
9 BIRTHPLACE
(State or country)
Burnham Me.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Maine.
12 MAIDEN NAME
OF MOTHER
Harriet Davis.
avis.
18 BIRTHPLACE
OF MOTHER
(State or country)
Maine.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Luther Sanford.
(Address)
Chelmsford Mars
16 Filed 82111, 1914Edward Grabbing
....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
(Month)
(Day)
6 DATE OF BIRTH
Jules
9
1845.
17
I HEREBY CERTIFY that I attended deceased from
1912 to
Dea 31et
1903
that I last saw her alive on.
.... ,
Die Best
191 3
....
and that death occurred, on the date stated above, at 12.00 en
The CAUSE OF DEATH* was as follows :
(Duration)
Several
................ yrs.
.mos. ds.
Contributory ...
(SECONDARY)
7 ...... (Duration)
.... yrs.
mos.
ds.
(Signed)
M.D.
Due 31 , 1913 (Address) Kowice Than
......
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
. yrs.
In the
mos.
ds.
State.
....... yrs.
......... mos.
.. ds
. ..........
Where was disease contracted, If not at place of death ?.
Former or usual residence. .......
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Edson Cemetery. Jan 3, 1914
ADDRESS
20 UNDERTAKER
Gao Makealey Sowell Mass
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
husband Elmira E Perkins Suther Sanford5 Registered No.
16 DATE OF DEATH
Dec
81
1913.
(Year)
" AGE
68 Vis. 5
.... yrs.
mos. 22 ds.
10 NAME OF
FATHER
Mark Perkins
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 firemun, 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 Ilousc- 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 Nonc.
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 usc of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeumt, etc , Carcinoma, Sar- coma, etc., of. .. (name origin: "Cancer" is less definite ; avoid use of "Tumor " for malignant neoplasmis) ; 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," "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 onc supposed to be due to Alcoholism, etc.
1. Deaths under circumstances unknown, as A person found dcad, ctc.
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 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
11 BIRTHPLACE OF FATHER (State or country) Milton Mass
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
Natation. Mass.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
1500 Middlein H. Lowell
16 Filed Jan. 1, 1914 Edward Wir affine
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
Female White
| 5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED LE
(Write the word)
Single
angle
· DATE OF BIRTH
July
(Month)
16
(Day)
1830
(Year)
"AGE
If LESS than
I day ......... hrs.
8.3
.......... yrs.
Mos. 15
ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
UL. Home
سد.
(b) General nature of Industry, business, or establishment in which employed (or employer) ...
(Duration)
yrs.
.mos ..
2
.ds.
Contributory ...
(SECONDARY)
(Duration)
... mos.
ds.
(Signed)
............
7 E Jamey
M.D.
Harry 1, 1914 (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 placo
of death
.yrs.
... mos.
ds.
State
In the
yrs.
mos.
ds
...
Where was disease contracted, If not at place of death ?..
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Chalnoord Mass.
DATE OF BURIAL Jan 2, 194
20 UNDERTAKER WH. Grunden Kowal Man
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Sarah Jane Beruf.
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
1553 Middlesex S. Lowell, Mass.
Registered No.
7€
16 DATE OF DEATH
Dec
...
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Dec 3r
1913 to
dec 31
19+3
....... .
that i last saw h .......... alive on Dec 31 1913 and that death occurred, on the date stated above, at 7,200 m. The CAUSE OF DEATH* was as follows : Lober Pneumonia
...........
9 BIRTHPLACE
(State or country)
Chelmsford. Mass.
10 NAME OF
FATHER
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford Mass (No)
St. :
Ward)
PERSONAL AND STATISTICAL PARTICULARS
247 Chelmsford Citrontown.)
.... yrs.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preeise statement of oceu- pation 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 oeeupations 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, cte. But in many eascs, 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 sceond statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specifieation, as Day laborer, Farm laborer, Laborer - Coal mine, cte. Women at home, who are engaged in the dutics of the household only (not paid House- keepers who rceeive 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 oeeupations of persons engaged in domestie serviee for wages, as Servant, Cook, Housemaid, ete. If the oeeupation has been changed or given up on aeeount of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that faet may be indieated thus: Farmer (retired, 6 yrs.). For persons who have no oeeu- pation whatever, write None.
Statement of cause of death. - Namc, first, the DIS- EASE CAUSING DEATII {the primary affeetion with respect to time and causation), using always the same aeeepted terin for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic eerebro-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., Careinoma, Sar- eoma, etc., of ......................... (name origin: "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronie valvular heart disease; Chronie interstitial nephritis, ete. The contributory (seeond- ary or intereurrent) affcetion need not be stated unless im- portant. Example: Measles (discase eausing death), 29 ds .; Broncho-pneumonia (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," cte.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shoek," "Uraemia," "Weakness,", cte., when a definite disease ean be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State eause 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 Medieal Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, cte.
2. Deaths supposedly eaused by violenec, 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 duc to Alcoholism, etc
4. Deaths under eireumstanees unknown, as A person found dcad, etc.
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