USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 16
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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 diseasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tubcr-
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. Doaths 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.
S SEX Mala. TAGE 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
I PLACE OF DEATH Hast Chefmurad IN
St. :
....
.........
Ward)
2 FULL NAME
Edward. F. Lundberg
¢
[If married or divorced woman or widow
give maiden name, also name of husband.1
@RESIDENCE
What Chefmylad Man.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
Celifor
175
1914
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
al
bril
, 1914 to
Del-172
.,
....
194
that I last saw ha alive on.
Del-17, 19/14
and that death occurred, on the date stated above, at 710
... m.
The CAUSE OF DEATH* was as follows :
Hyderafichus.
(Imbaby sharki)
.... (Duration)
............ yrs.
........
mos.
ds.
10 NAME OF
FATHER
Paul. Lundberg
11 BIRTHPLACE
OF FATHER
(State or country)
Sweden.
12 MAIDEN NAME
OF MOTHER
anna. Murman
13 BIRTHPLACE
OF MOTHER
(State or country)
Sueden
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Paul. Lundberg
(Address)
that Chefmail .the
15 Oct 16, 194 Caward . Salling
1472
REGISTRAR
1265
-
Sing.s.
1
(Day) (Year)
If LESS than
| day ......... hrs.
or ........ min. ?
+
& 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)
) Part Chelmikail Plan
Contributory
(SECONDARY)
.(Duration)
.yrs.
.mos.
ds.
JE Varney
M.D.
.
(Signed)
04.18
n. chef 9
* 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
DATE OF BURIAL
Hert Chefmyal Candy Oct /7, 1914
20 UNDERTAKER
ADDRESS
David Bereist Son. Merkad Mars
60 Chefensinal. (City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
.
Registered No.
60
4 COLOR OR RACE
Thrite.
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
March.
1914
(Month)
.. yrs.
7
mos.
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, 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 -Coalsnine, 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," 86 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
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 ..
.....
Susan augusta
Verry
Chelruepod 6
...
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Hemale
4 COLOR OR RACE
white
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
$ DATE OF BIRTH
aug 14 1849,
(Month)
(Day)
...
(Year)
TAGE
65 yrs. 2
mos.
8
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)
Dracut
10 NAME OF
FATHER
Chas Perry
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Sherburne Mark
12 MAIDEN NAME
OF MOTHER
Susan a Baroin
13 BIRTHPLACE
OF MOTHER
(State or country)
Concord n.H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Seo Perry
(Address)
Chelmsford
15
Filed Oct. 24 ) X Edward bottoms
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
act.
220
.... ,
1914 ........
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
aug. 19
......... .
1914, to
Oct. 22nd
1914
....
If LESS than I day ... ....... hrs. that I last saw her alive on.
act, 22 nd
, 1914
and that death occurred, on the date stated above, at 3 P.m.
The CAUSE OF DEATH* was as follows :
Chronic Endocarditis
......
4-mas. To my Knowledge Mlnown (Duration) yrs. . ................ mos. ds.
Contributory ..
(SECONDARY)
... (Duration) ............... yrs. ............ .. mos. ................ ds.
(Signed)
Amasastoward
M.D.
act. 23, 1914 (Address).
Chelmsford Mari
* 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
ds.
mos.
State.
.. yrs.
RECENT RESIDENTS).
At place
of death
. 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 Pine Ridge Com
DATE OF BURIAL
Och 24, 1914
20 UNDERTAKER
Perhour
ADDRESS
Chelcustos
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
2FULL NAME. [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
St. :
.................
Ward)
Registered No.
6%
ad
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- EASE 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 opcration 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.
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 Lourd, Mass. (No 7. When Hospital St. :.. Ward)
2 FULL NAME
hoseth roulet
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Tymstro Rd. north Chelmsford
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
white
5 SINGLE
MARRIED,
WIDOWED,
OR /DIVORCED
(Write the word)
Widowed
6 DATE OF BIRTH
1866
(Month)
(Day)
(Year)
7 AGE
48
.... yrs.
.. mos.
ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
amale
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Canada
10 NAME OF
FATHER
ambroise Soulet
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Canada
12 MAIDEN NAME
OF MOTHER
angelina Du quette.
13 BIRTHPLACE
OF MOTHER
(State or countyy)
Canada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Samuel Goulet.
(Address)
50% Surade.
Filed.
Nov. 3 1914 Edward JRalbay
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
nov.
(Month)
2,
(Day)
1914
(Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
accident
" Run our la ang":)
(Duration)
.yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration)
.... yrs.
.. mos.
ds
(Signed)
nu. 3
.. ,
191 ...
(Address) HallenwackXX
M.D.
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, OR RECENT RESIDENTS).
In the
At place
of death
. yrs.
mos.
ds.
State
yrs.
mos.
ds.
Where was dlsease contracted, if not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL St Joseph's
DATE OF BURIAL
nov.1
191
20 UNDERTAKER
& albert
ADDRESS
171 arken
62
62
(City or town.) Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
important. See instructions on back of certificate.
16
17
If LESS than
| day ......... hrs.
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 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 occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie ecrebro-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 .; 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," "Shoek," "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 eause 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 carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under tho head of "Contributory."
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 strcet, or one supposed to be due to Alcoholism, etc.
4. Deatlıs under circumstances unknown, as A person found dead, etc,
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
2 FULL NAME .. SEX Male 9 BIRTHPLACE (State or country) 12 MAIDEN NAME OF MOTHER 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
lehelmsford
.(No
Dalton Road
St. :
Ward)
Thomas E Buckman
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Cheleford
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
nor.
5th
(Month)
(Day)
(Year)
18.36 17 I HEREBY CERTIFY that I attended deceased from
(Year)
ana.
,
1913, to.
nor.
1914
7 .....:
If LESS than
i day .......
;........ hrs.
that I fast saw h.k.xx ... alive on.
nov.1
, 1914
and that death occurred, on the date stated above, at 3P.m.
The CAUSE OF DEATH* was as follows :
Myrcarditis
.
(Duration).
1
.. yrs.
mos.
ds.
Contributory ..
Senility
(SECONDARY)
.(Duration) .
.........
... yrs.
.mos. ds.
(Signed)
amaca stoward.
M.D.
nov. 7
191
...
(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.
In the
ds.
State ..
... yrs.
.mos.
ds ...
....
Where was disease contracted, if not at place of death ?.
... Former or usual residence. .............
14 THE ABOVEIS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mr. Fred a Breeller
(Address)
Chelmsford -
16 Filed nov. 1 1914 Edreaded Je Robbins
REGISTRAR
Chelmsford 63
...
......
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
63
4 COLOR OR RACE
wollte
-
5 SINGLE
MARRIED
WIDOWED, Ledower
(Write the word)
· DATE OF BIRTH
March
(Month)
(Day)
PAGE
78 . 7
... yrs ..
... mos.
.......
ds.
or ......... min. ?
8 OCCUPATION
-
(a) Trade; profession, or
particular kind of work.
Detried Farmer
(b) General nature of industry, business, or establishment in which employed (or employer).
Maine
10 NAME OF
FATHER
Buckman,
11 BIRTHPLACE
OF FATHER
(State or country)
-
18 BIRTHPLACE
OF MOTHER
(State or country)
V
191.
4
DATE OF BURIAL
19 PLACE OF BURIAL OR REMOVAL
Edlow Cem Lowell Nov. 8
20 UNDERTAKER
ADDRESS
Waller Tenham Chelmetal
1914
.......
...
......
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oeeu- 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," ete., 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.
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