USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1912-1913 > Part 9
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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.
122
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1912.
CITY OF
BOSTON.
FULL NAME
JOSEPHINE F. QUIGLEY
Registered No .. 5.684
ST.ELIZABETHS HOSPT.
Place of Death Boston
and Residence
JUNE 17
42
Date of Death
1912.
ge
..
years
.months. days.
STATISTICAL DETAILS.
PHYSICIAN'S CERTIFICATE.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
F
W
M.A.R ..
Maiden Name
MC CABE
EGIST WILLIAM H. QUIGIEM PATIO
RAR'S
SIT Primary (Duration)
PUERPERAL SEPTI.CAEMIA ....- 10 DYS
Husband's Name ..
DITY NORTH CHELMSFORD
Birthplace
BOSTONSTA CONDITA AL
Name of
Father. HENRY MC CABE
BOSTON
Birthplace IRELAND
of Father.
Maiden Name
of Mother .. MARGARET MC COY
Birthplace of Mother.
IRELAND
Occupation
HOUSEWIFE
Informant
Place of Burial LOWELL(ST PATRICKS)
or removal.
J.F.O DONNELL & SONS
Undertaker.
LOWELL
Usual Residence
NO. CHELMSFORD (PRINCETON ST)
Filed
JUNE 20
1912
A true copy.
Attest :
EumElement
Registrar.
MARGIN RESERVED FOR BINDING. ·
I HEREBY CERTIFY that | attended deceased during fast illness,
1912, from 1912, to that to the best of my knowledge and belief death occurred, on the date stated above, and that the CAUSE OF DEATH was as follows :
OFICE
&SILVLIAJJ
1810
YATA A. 1822.
MASS. Contributory : { (Duration) 1
(Signed)
LOUIS .... CROKE
M.D.
JUNE 17 1912
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
:
บลิดีเละLL
D
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. (No. Highland Ave.
Barrie A Smith.
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE No. Chelmsford, Mass,
Carrie, A. Rowell, C. Sherman &Smith Registered No.
37
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Females
4 COLOR OR RACE
White.
5 SINGLE
MARRIED,
Married
OR DIVORCED (Write the word)
6 DATE OF BIRTH March 14. 1875. (Month) (Year)
(Day)
7 AGE
37
.yrs.
3
mos.
3
ds.
.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
At Home.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
At Home
9 BIRTHPLACE
(State or country)
Exeter, N.H.
10 NAME OF
FATHER
Frank Frank Z. Rowell.
PARENTS
12 MAIDEN NAME
OF MOTHER
Marry by Garland
13 BIRTHPLACE
OF MOTHER
(State or country)
Epping, N. 71.
14 THE ABOVE IS TRUE TO THE BEST OF NY KNOWLEDGE (Informant) By herman Smith.
(Address) No 6 helms ford, Maser
16 Filed Jime 17, 1912 Edwald &. Robbing
REGISTRAR
16 DATE OF DEATH
June
17.
(Day)
(Month)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
8. 1912 to
June 16
1912
Anna 16
1912
and that death occurred, on the date stated above, 7.10 A.
The CAUSE OF DEATH* was as follows : Pneumonia
(complicating measles
(Duration)
.. yrs.
mos.
6
ds .
Contributory (SECONDARY)
(Duration)
mos.
ds.
(Signed)
June17 97 (Address) enouvelle horade
-
* 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.
In the
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 Brentwood N.H.
DATE OF BURIAL
June 20. 1912.
20 UNDERTAKER
GrafDealey
ADDRESS
79Branch 88.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
123 No Chelmsford. (City orte5) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Ward)
-
If LESS than [ day, ...... hrs. that I last saw h EL alive on
.,
M.D.
11 BIRTHPLACE OF FATHER (State or country) Brentwood N. H.
STANDARD CERTIFICATE OF DEATH. 3
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: Cercbro-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," " All- 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 onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelinford Mass No hat Chelies fond
St. :
Ward)
(City of town.) [If death occurred in a hospital or institution, give its NAME Insteed of street and number.]
Millicent aun Brady 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
That Chelwex ford Mais
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
& SEX
timale
4 COLOR OR RACE
White
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
Ving 6
16 DATE OF DEATH
June
19
...
(Month)
(Day)
(Year)
6 DATE OF BIRTH
Dum
29 1883
0
(Month)
(Day)
(Year)
7 AGE
If LESS than ! day ......... hrs.
28
............ yrs.
11
mos.
19
ds.
or ......... min. ?
& OCCUPATION
(a) Trede, profession, or
particular kind of work
Domestic
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Gravidemy R.V.
10 NAME OF
FATHER
John Brandy
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Jat Juni
12 MAIDEN NAME
OF MOTHER
Un Donahue
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 2x
(Informent)
John Sum vinter other
(Address)
What Chiley board Mas
16 Filed Jsme 20 1912, Covered S. Rabbim
REGISTRAR
17
.........
I HEREBY CERTIFY that I attended deceased from
01.26
1911
.... to Auma 19
1912
that I last saw halive
6June 18
1912
and that death occurred, on the date stated above, at 2 45 am.
The CAUSE OF DEATH* was as follows :
Pulmonary tuberculosis
...
(Duration)
yrs.
10
mos.
ds.
Contributory ...
(SECONDARY)
(Duration)
.... yrs.
.mos.
ds.
(Signed)
JE Varer
....
M.D.
farma /9, 1912 (Address)
H. Cholenders,
....
* 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 of usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
June 2/ 1912
...........
/ADDRESS
20 UNDERTAKER
Det Dowell NJord 324 Marget US.
Chelin ford Mer 124
-
.
Registered No.
38
191.2
......
...
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 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 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
4
St. ;
Ward)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
1 PLACE OF DEATH
C
.(No.
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
White
Irish
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
May
I
-
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day, ....... hrs.
35
-
or ......... min. ?
......... yrs ..
/
.mos.
ds.
8 OCCUPATION
at Home
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
Housework
which employed (or employer).
9 BIRTHPLACE
(State or country)
Ioland
10 NAME OF
Peter Riley
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Ellen Burz
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Husband
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.
(Address)
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
....
16 Filed June 21, 1912 dered Y, Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Image 20
191 7
(Year)
(Month)
(Day)
17
I HEREBY CERTIFY that I attended deceased from
apr 29, 197 to.
.........
June 19 92
that I last saw het alive on.
June 19, 1912
and that death occurred, on the (date stated above, at ..................
.m.
The CAUSE OF DEATH* was as follows :
(Pulmonary Tuberculosis
....
...
(Duration)
1
... yrs.
mos.
ds.
Contributory .. (SECONDARY)
(Duration)
mos.
........... yrs.
......
ds.
(signed)
A
M.D.
Jo ZO, 1912 (Address).
.......... ,
scofora,
Chelmsford, 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).
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
St Patrick howell June 2912
ADDRESS
20 UNDERTAKER
l has to Molloy Lowell
Chelnghe 425
(City or town.)
ny Lovcraft.
Mary Riley Welson Loucraft
Registered No. 39
farmingial
....
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
1 PLACE OF DEATH Chelmsford (60) Sorhow St. 6. Ch
1833
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
40
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
₹
Anne
22
(Month)
(Day)
1912
(Year)
17 I HEREBY CERTIFY that IAttended deceased from 1908, to 1
Jan 22
, 1912
that I last saw him alive on Andre 22 ..... . 1912 and that death occurred, on the dato stated above, at m. The CAUSE OF DEATH* was as follows :
Spostati Ducase-
about (Duration)
5
.... yrs.
mos. ds.
Contributory ..
(SECONDARY)
(Duration) .... yrs.
.. mos. ds.
(Signed)
arthur Scoloria
M.D.
Joom 23. 192 (Address).
Clubmix and maso
* 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 Edson Cene
DATE OF BURIAL
June 24- 1912
20 UNDERTAKER
Walter Pertama
ADDRESS
Filed.
16 June 24, 1912 Edward , Robbins
REGISTRAR
126 Chelmsford (City or town.)
Peter Pepin
2FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
5 SINGLE,
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
male
4 COLOR OR RACE
white
6 DATE OF BIRTH
nov
11
-
(Month)
..
(Day)
7 AGE
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Farmer
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Canada
10 NAME OF
FATHER
Peter Repair
11 BIRTHPLACE
OF FATHER
(State or country)
Canada
12 MAIDEN NAME
OF MOTHER
Angeline Parquett
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
Canada
14THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
My Elin Patenand
important. See instructions on back of certificate.
(Address)
E. Chelmsford
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
78
... yrs.
7
mos.
11
ds.
or ........ min. ?
widowed
1833 (Year)
If LESS than I day ......... hrs.
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, 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 second statement. Never return " Laborer," " Foreman," " Manager," " Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Ilousewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING 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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