USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 17
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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 septicemia," "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 Medical Examiners:
1. Deaths following injury or violenee, 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.
5
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
Cheli ford Pass (No.
Westland
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
het
' DATE OF BIRTH May
(Month)
(Day)
1
(Year)
7 AGE
.... If LESS than I day ......... hrs.
........ ............ yrs. mos. ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
- particulat-kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
island
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or country) uland
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country}
luland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ...
) and telly, Dove
(Address) Chelisted Center
Filed_ Nov. 9, 1914 Eduard . Bobbing .....
REGISTRAR
16 DATE OF DEATH
nov.
7
1914. ....
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from Och.17
.. 1914, to
nov.5, 1914.
1
that I last saw ham alive on.
nor5, 1914.
L
and that death occurred, on the date stated above, at. .m. The CAUSE OF DEATH* was as follows : Senile Degeneration
arteriosclerosis
.(Duration)
... yrs.
mos.
ds.
Contributory ... (SECONDARY)
(Duration)
0y
mos.
ds.
(Signed)
Arthurt, Ocobarra
201. 7, 1914 (Address)
Checkingford, Make
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
In the
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
mos.
ds.
of death.
.. yrs.
.mos.
ds.
State
.yrs.
Where was disease contracted, If not at place of death ?. Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL Stabucks Camely NUL-9, 1914
20 UNDERTAKER
ADDRESS
-
৳ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
11
....
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husbandA
@RESIDENCE
Stratford Ut. Chelwoord Center
-
Registered No.
64
....
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," "Dcaler," 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. - Namc, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time aud 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, ctc. -
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
65
11.30 a.
.m.
ds.
4
20 UNDERTAKER
Walter Perham
...........
REGISTRAR
Lowell 1 PLACE OF DEATH (City or town.) Lowell, Mass. (No Lowell Hospital St. ; Ward) fif death occurred in a hospital or institution, give its NAME Instead of street and number.] 2 FULL NAME Robert W. Vickery [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford, Mass. Registered No. 1541 PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH 3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED WIDOWED, (Month) Male write OR DIVORCED ( Write the word) Single 16 DATE OF DEATH (Year) (Day) 1914 November 11, & DATE OF BIRTH 17 February 28, 1914. I HEREBY CERTIFY that I attended deceased from 1 (Month) (Day) (Year) Nov. 5. 191 4. to. Nov. 11, 191 4 If LESS than 7 AGE 1 day ......... hrs. .... that I last saw h Im alive on. Nov. 11. 19| 4 .yrs. and that death occurred, on the date stated above, at. 8 mos. 11 ds. Or ......... min. ? ... 8 OCCUPATION (a) Trade, profession, or particular kind of work The CAUSE OF DEATH* was as follows : Cerebral Embolism ------ (b) General nature of industry, business, or establishment in which employed (or employer) ... 9 BIRTHPLACE (State or country) (Duration) .yrs. mos. Lowell, Mass. Contributory. Septic Infected Genitalia 10 NAME OF (SECONDARY) FATHER .(Duration) .yrs. mos. ds. ....... Elmer w. Vickery (Signed) E. J. Clark M.D. 11 BIRTHPLACE OF FATHER * If death followed injury or violence the certificate of death must be made owell out by the Medical Examiner. (State or country) Roxbury, Mass. Nov. . 12. 1.4 ...... (Address). Lowell Hospital. 12 MAIDEN NAME OF MOTHER PARENTS Inez Derby 18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS). At place In the of death .... yrs. mos. ... ds. State .... ............ yrs. ............ ... mos. ...... ds ............. 18 BIRTHPLACE OF MOTHER (State or country) Where was dlsease contracted, Former or Lowell, MASD. If not at place of death ?. ........ 14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE usual residence. (Informant) Mrs. Elmer Vickery 19 PLACE OF BURIAL OR REMOVAL important. See instructions on back of certificate. (Address) CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very Chelmsford, Mass. Forefathers' Cem. Chelmsford Massa DATE OF BURIAL I.cv. 12 191 15 Filed Nov. 13 N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state ...... ........ ....
ADDRESS
Chelmsford,
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- DASE 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 (ncver 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," ete. 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.
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 Y AGE 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
Chelmsford
.......
.(No
Brelow Road
....
Selvvia Lucent.
Dechardson: ....
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford.
Heaward Richardeur
Registered No.
66
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIEB,
WIDOW Ha dow
(Write the word)
$ DATE OF BIRTH
april
(Month)
(Day)
(Yer)
If LESS than 1 day ......... hrs.
87
... yrs.
6
mos.
22.
ds .
or ........ min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work ...
(b) General nature of industry, business, or establishment an which employed (or employer) .....
9 BIRTHPLACE
(State or country)
ry) Carlisle Mass.
10 NAME OF
FATHER
lilly Guen
11 BIRTHPLACE
OF FATHER
(State or country)
Carlisle
12 MAIDEN NAME
OF MOTHER
Polly Lane
13 BIRTHPLACE
OF MOTHER
(State or country)
Carlile
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
a. H. Davis
15 Filed Nr. 14. 1914 Edward Rollers
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH nov. 12 .... . 1914 ...
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Sept. 21
. 1914 to
........ ,
nor. 11 194
that I last saw her alive on.
Nor 11, 1914
and that death occurred, on the date stated above, at a.m.
The CAUSE OF DEATH* was as follows :
Fracture of right hip -
Denelite
(Duration)
yrs.
mos.
ds.
...
Contributory ..
(SECONDARY)
(Duration)
.......... yrs.
. ...
.mos.
ds.
(Signed)
Arthur S. Scoloria
M.D.
nov.1 3, 1914 (Address).
Chilsford, mais
* 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.
...
.. 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
Carlile mar Nov. 14
1917
ADDRESS
20 UNDERTAKER
Walter Luckand Cheliosfel
Chelmefind
........
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. :
Ward)
......
2 FULL NAME
4 COLOR OR RACE
Witte
20
1827
...............................................................
1
..................
In the
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 (retircd, 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 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 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.
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
1
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Thert Chemin, No. Man
......
St. ;....................
Ward)
(City or town.) [If death occurred in a hospital or institution, give ita NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Mala.
4 COLOR OR RACE
White
1 5 SINGLE,
MARRIED,
marvel
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Jan-13
(Month)
185.3
1
(Year)
TAGE
If LESS than
! day ......... hrs.
61 yrs. 10 mos. 10 ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Willy Operator
.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Shirt Chefnurfed.
PARENTS
12 MAIDEN NAME
OF MOTHER
Harriet Sherwood.
13 BIRTHPLACE'
OF MOTHER
(State or country)
England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
quiz Ena
Cathay.
(Address)
15
File
for 23, 1914 Edward & Robbery
REGISTRAR
1265-
1472
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Nov., 23
1914
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Kept, IS, 1914, to Nov 23
....
1914.
that I last saw him alive on Nov 22
....
191
... .
and that death occurred, on the date stated above, at 25 Am.
The CAUSE OF DEATH* was as follows
..
Carcin
11
of Prostate
(Duration)
7
yrs.
.mos.
ds.
Contributory ...
(SECONDARY)
(Duration)
.... yrs.
.mos.
ds.
M.D.
(Signed)
Mar23
WeerLand Mass
......
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
of death,
yrs.
... mos.
ds.
State ...
............ y.s.
....
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
That Chefmed 1 Mar 25
Camilly
1914
ADDRESS
20 UNDERTAKER
David & Grice Son Ofertad /cz.
67
Robert E. Caffroy
.
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of, husband.1
@RESIDENCE
That Culminar. Man.
Registered No.
67
(Day)
10 NAME OF
FATHER
John Jaffray.
11 BIRTHPLACE
OF FATHER
(State or country)
Canada.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursnits 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 Ilouse- 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.
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