USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 18
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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," "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.
1
=
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Lowell, Mass. (No. Chelmsford St. Hospital.
68
Lowell
-.
(City or town.)
[if death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
Elizabeth Meehan
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford, Mass.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
December
16. 1914.
191
(Year)
(Month)
(Day)
17
I HEREBY CERTIFY that I attended deceased from
Der. 15.
19| 4 . Dec. 16,
1914
........ ,
....
that | last saw h ...... MA alive on.
Dec. 15
19| 4
and that death occurred, on the date stated above, at5 P. m.
The CAUSE OF DEATH* was as follows :
Mitral Regurgitation
(Duration)
.. yrs.
mos.
ds.
Contributory
Alcoholism
(SECONDARY)
.(Duration)
.... yrs.
mos.
1.4ds.
(Signed)
M. A. Tighe
M.D.
Dec. 17 .914 (Address).
9 Central St.
* 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
DATE OF BURIAL
St. Patrick's Cemetery . Dec.19
4
191
ADDRESS Lowell
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
1 PLACE OF DEATH 3 SEX Female & DATE OF BIRTH PAGE 8 OCCUPATION (b) General nature of industry, business, or establishment in which employed (or employer) .... PARENTS 13 BIRTHPLACE OF MOTHER (State or country) (Informant) . important. See instructions on back of certificate. CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very (Address) 15 Dec. 18 4 Filed 191 ... N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state ......
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
-----
(Month)
(Day)
1
(Year)
If LESS than
I day .......... hrs.
21 ...... yrs. 1 0mos. .ds.
Or ......... min. ?
(a) Trade, profession, Housekeeper
particular kind of work-
9 BIRTHPLACE
(State or country)
Lowell, Mass.
10 NAME OF FATHER John Meehan
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Ann Shanley
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Father
Chelmsford, Mass.
REGISTRAR
20 UNDERTAKER
Molloy
Ward)
Registered No.
-
68 1700
....
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 linc 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) Groccry; (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 arc 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 Nonc.
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 merc symptoms or terminal conditions, such as "Asthenia,". "An- acmia" (merely symptomatic), "Atrophy," "Collapsc," "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 Examnincrs;
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.
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
LPLACE OF DEATH
Chelmsford
(No.
Westford Road
Willie Celeffend Ward
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE lehelivesford.
Registered No.
69
PERSONAL AND STATISTICAL PARTICULARS
& SEX
M.
4 COLOR OR RACE
w.
5 SINGLE,
MARRIED.
WIDOWED Married
OR DIVORCE6
(Write the word)
$ DATE OF BIRTH
let.
13
1891
(Month)
(Day)
(Yeaf)
TAGE
43
.... yrs ... 1 mos, 20 ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
make
Onehector of Cultores
(b) General nature of industry,
business, or establishment in
which employed (or employer).
Boston mais
9 BIRTHPLACE (State or country) Lowell
10 NAME OF
FATHER
Chas le Ward.
PARENTS
12 MAIDEN NAME
OF MOTHER
Sarah Mudgett
13 BIRTHPLACE
OF MOTHER
(State or country)
Maine
1
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Caroline Ward
(Address)
15 DEC. 5 DJ. Robbin
.....
REGISTRAR
/
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec. 2 nd
(Month)
(Day)
191.
(Year)
Dec 2
1914
17
1914 to
.... ,
I HEREBY CERTIFY that I attended deceased from
nov. 15%
....
....
that I last saw him .... alive on.
Dec. 1
1914
...
and that death occurred, on the date stated above, at + a.m.
The CAUSE OF DEATH* was as follows :
Sabar. Pneumonia.
.(Duration)
.yrs.
.mos.
16
.ds.
-
Contributory
(SECONDARY)
(Duration)yrs.
.mos.
......
ds.
(Signed)
amara Stoward
M.D.
Dec. 3
1914 (Address).
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
Forefathers Gen
Chequesfund Man
DATE OF BURIAL
Dlec. 5. 1914
..............
20 UNDERTAKER
Waller Puchary
ADDRESS
Chelmsford.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
69
Chechueford.
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. ;.......
.......
Ward)
2 FULL NAME
Filed , 1914 Edward
....
If LESS than
I day,
..... hrs.
11 BIRTHPLACE
OF FATHER
(State or country) .
Havingtied Vermont
.........
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 dutics 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 septicemia," "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.
1
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
1 PLACE OF DEATH 2 FULL NAME 3 SEX · DATE OF BIRTH AGE & OCCUPATION (a) Trade, profession, or particular kind of workxmm (b) General nature of industry, business, or establishment in which employed (or employer) PARENTS 18 BIRTHPLACE HER OF MOTHER (State or country) 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 ...... .... yrs.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
......
.........
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Catref & Cuman
[If married or divorced woman dr widow give maiden name, also name of husband.] @RESIDENCE Lancton Boulevard horacheln geistig No.
70
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
DEG
3
(Month)
(Day)
1914
(Yeaf)
17 I HEREBY CERTIFY that attended deceased from
Sept 20 1914/ to
Dec 3m
191.
.........
4 that I last saw h Whalive on.
Dec 3
191.
. ....... and that death occurred, on the date stated above, at 18:%
m.
The CAUSE OF DEATH* was as follows : Myocarditis
.........
.. (Duration)
2%
............. yrs.
„.mos.
ds.
12
Contributory ..
(SECONDARY)
....
J. Welch
.. yrs. ............
... mos.
............
„ds.
(Signed)
......
Dec 4. 1914 (Addres).
2) Panels Boldi
* 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.
.......
Where was disease contracted, If not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
20 UNDERTAKER
ADDRESS
REGISTRAR
1 5 SINGLE MARRIED WIDOWED./.
(Month) (Day)
1
(Year)
If LESS than 1 day ...... .. hrs.
.......
mos.
ds.
or ......... min. ?
9 BIRTHPLACE (State or country) eiland
30 NAME OF
FATHER
John Curran
11 BIRTHPLACE OF FATHER (State or country) wand
12 MAIDEN NAME OF MOTHER Margaret melia
Leland
" THE ABOVE AS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) the lunar song
(Address) In ACheline fond
Filed. Dec. 6 . 1914 Educada Du Rotting
70
.Ward)
...
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
Story-Keeper
.... (Duratfin) .....
.............
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to each and every person, irrespective of age. For many 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 (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 (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," "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 eause for which surgieal 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 discase, 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. - ........ Smith av.
Henry W. Smith
2 FULL NAME
[If married or divorced womau or widow
give maiden name, also name of husband.]
@RESIDENCE
Imith Cv. Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR QR RACE
NTuto
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH Dec 22-1878 (Month) (Day)
1
(Year)
7 AGE
If LESS than | day, ........ hrs.
36
.yrs. // mos.
ds.
or ........ min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work Garnier
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Lowell
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or country) cin guista mama_
12 MAIDEN NAME OF MOTHER ( Bredger Welchs
13 BIRTHPLACE OF MOTHER (State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
John. TrSmuts
(Address) Chiluntad Tu ass
15
Filed
Dec. 20 1914 Edward . Rotting
L -REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Drc 17
(Month)
(Day)
94
(Year)
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
Suicide ty Prison
(Carbolic acid)
(Duration)
.. yrs.
mos. ds.
Contributory
(SECONDARY)
(Duration) .. yrs.
.mos. ds.
(Signed)
Fre IA, 1966 (Address) 160 Merhamet H
1
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 disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
Edson Country
DATE OF BURIAL
Dec 2019
20 UNDERTAKER
ADDRESS
3.3 (Quecorsoe)
Chelmsford ... (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. :
Ward)
Registered No.
71
.
....
important. See instructions on back of certificate.
.
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 specifieation, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who arc engaged in the duties of the household only (not paid Housc- 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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