USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 15
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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, 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," "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.
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
Lowell, Mass. (No. Lowell General Hospitalt .;
Ward)
(City or town.) [if death occurred in a hospital or institution, give Its NAME Instead of street and number.]
2 FULL NAME
Mathilda R. Pearson
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Forth Chelmsford Mass.
Mathilda I. Mayor
Henry Pearson
...
56
Registered No. 1313
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
& SEX
Temale
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
WIDOWED,
Married
OR DIVORCED (Write the word)
16 DATE OF DEATH
September 30, 1914
191.
....
(Month) (Day)
(Year)
6 DATE OF BIRTH
December 8,
1865
1
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day ......... hrs.
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).
Peritonitis
(Duration). .yrs. mos. ds.
Contributory
(SECONDARY)
(Duration)
... yrs.
mos.
ds.
(Signed)
Arthur C. sdoboria
M.D.
sct. 1 , . 191 4 (Address) Chelmsfrod, Hass.
* 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 Chelmsford, Mass.
DATE OF BURIAL
oct. 2,
4
191
16 UCt.
Flied.
191 ...
11.
1
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
Sept. 29,
. 4
Sept. 27
191 4 .
191.
..........
....... , to
that I last saw h ..... e.T. alive on
Sept. 39,
... , 19| 4
and that death occurred, on the date stated above, at 9 am.
The CAUSE OF DEATH* was as follows : Autointoxication from
....
9 BIRTHPLACE
(State or country)
Sweden
10 NAME OF
FATHER
Johnson Mayor
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Sweden
12 MAIDEN NAME
OF MOTHER
Hannah Britta
18 BIRTHPLACE
OF MOTHER
(State or country) Sweden
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Henry Pearson
(Address)
20 UNDERTAKER
wm.
Saunders
ADDRESS
Lowell.
56
Lowell .....
...
MARGIN RESERVED FOR BINDING
48
... yrs.
9
mos.
22 ds.
Intestinal Obstruction --
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 cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engincer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it i3 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 nceded. 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 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 homc. Care should be taken to report specifically the occupations of persons engaged in domestic serviec for wages, as Scrvant, 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- DASE 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 synonyın is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, cte., of „(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ctc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (discasc causing death), 29 ds .; Broncho-pneumonia (sccondary), 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," "Wcakness," 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 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- posurc, ete.
3. Sudden deaths of persons not disabled by recognized discasc, as A death upon the street, or one supposed to be due to Alcoholism, ctc
4. Deaths under circumstances unknown, as A person found dead, ctc.
1
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
7 AGE PARENTS important. See instructions on back of certificate. 16 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 Fath Chele fond (No Princeton
St. ;....................... Ward)
(City or town.) 5 [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No. 57
PERSONAL AND STATISTICAL PARTICULARS
3 SEX,
Jecual Ahit,
{ COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Jedound
· DATE OF BIRTH
-
(Month)
(Day)
1829
(Year)
If LESS than
[ day ......... hrs.
-
.. yrs.
mos. ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work ..
Detund
(b) General nature of industry,
business, or establishment In
which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Scotland
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE
OF MOTHER
(State or country)
11
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant trang f &Hogan Smith Taw (Address) Puncton A. frits Cheluc And
Filed act 3, 1914 Edward ). Rolling ..............
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
Sept 27, 1914.
Oct
to 2, 1914 that I last saw h&m alive on Bet, 1, 1914 and that death occurred, on the date stated above, at 10a .m. The CAUSE OF DEATH* was as follows :
Sente Obillos
(Duration) .yrs.
mos.
ds.
Contributory ...
(SECONDARY)
(Duration) ........ .... yrs.
mos. ds.
(Signed)
saures
11
M.D.
.......
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 place
In the
of death
yrs.
. mos.
ds.
State ...
........... y ... ........
....... 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 Oct 4 1914
....
20 UNDERTAKER Para F. Ohowwell
ADDRESS 3.24 Manget VS.
.......
(Month)
(Day)
1917 (Year)
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Oct
10
4 ..........
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Paneton Street"
Varah 3: On, Heach Predicar
Sarah
Poudreay
2 FULL NAME
both Cheli ford
arteño Celosia
....
1
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- 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 occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- BASE 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 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.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX 8 OCCUPATION PARENTS important. See instructions on back of certificate. (Address) 16 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
Chamafond
(No
Barton Road
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
(Marner)
Warmea Baillece- Parquet
2FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelios Ford
Registered No.
58
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Oct
3
94
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
.,
191
to
Oct 3
1914
that I last saw him alive on. 191 .. ,
and that death occurred, on the dato stated above, at
m.
The CAUSE OF DEATH* was as follows :
Angina Pectoris
-
-
1
(Duration)
.yrs.
mos.
ds.
Contributory.
(SECONDARY)
.(Duration)
... yrs.
mos. ds
(Signed)
Cod.3
, 1917 (Address) ..
Chelmsford
* 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.
ds. mos. .... Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Milford IV.H.
DATE OF BURIAL
Oct. 16
1914
Filed Det. 3 19 4 Edward Putting
(REGISTRAR
5 SINGLE,
MARRIED
WIDOWED,
Married
(Write the word)
6 DATE OF BIRTH
November
(Month)
(Day)
1848 (Year)
AGE 65
If LESS than | day, ........ hrs.
.yrs.
11
mos.
3
ds.
.
or ......... min. ?
Machania
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Hollis, N. H.
10 NAME OF
FATHER
William Sargent
11 BIRTHPLACE
OF FATHER
Mate or country) Milford N. H.
12 MAIDEN NAME
OF MOTHER
Mariali Tatlı
13 BIRTHPLACE
OF MOTHER .
(State or country)
Hollis N. H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Was W. B. Salget
20 UNDERTAKER Waller Fechar
ADDRESS
Chelmsford
.
5.8 Cachuaford
In the
M.D.
(a)' Trade, profession, or
particular kind of work
4 COLOR OR RACE
White
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 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) Salcs- 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, peritonacum, etc., Careinoma, 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," "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 septieaemia," " 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.
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 Steadman
St. ;
Ward)
(City of town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2FULL NAME [If married or divorced woman or widow give maiden name, also pome of husband.] @RESIDENCE Chelineford,
lehas. P
1. O. E. B. Yeator
Registered No. 59
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
7.
4 COLOR OR RACE
White
& SINGLE,
MARRIED
WIDOWE
OR DIValidere dow
(Write the word)
6 DATE OF BIRTH
(Month)
(Day)
8 1849 (Year)
7 AGE
If LESS than
| day, ........ hrs.
65
.yrs.
mos.
.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).
9 BIRTHPLACE
(State or country)
Epson N.H.
PARENTS
12 MAIDEN NAME
OF MOTHER
Mary a Hillard
13 BIRTHPLACE OF MOTHER (State or country) Chichester, N.H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. Mary J. Willey
(Address)
chelineford. Mars.
15 Filed .. Oct.9 9 4 Edward Job Jobbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
October
$
T
(Month)
(Day)
191:
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Sept 18, 1914, to Chat 8
1914
.......
,
that I last saw he alive on.
1914
and that death occurred, on the date stated above, at 4 a.m.
The CAUSE OF DEATH* was as follows :
Clinic interstitial replication
,
.(Duration)
.... yrs.
......
.mos.
ds.
Contributory.
Chemin valiseles heart
(SECONDARY)
weare with failure of comper
.... (Duration)
yes. 2 mos.
V
ds.
(Signed)
Marshall L. Alling.
M.D.
det 9
.....
191
(Address) Romel Mates.
* 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 Suncook n.H.
DATE OF BURIAL
Cet 10 1914
ADDRESS
20 UNDERTAKER
Walter tenham Chelmsford
important. See instructions on back of certificate.
10 NAME OF
FATHER
Solomon Yeaton
11 BIRTHPLACE
OF FATHER
(State or country)
Epson N. H.
..
Grace Bridge
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 eacli 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) Salcs- 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 Housc- 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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