USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 19
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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, peritonacum, etc., Carcinoma, Sar- coma, ete., 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 discases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause 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 the 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 Medieal Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly eaused 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 important. See instructions on back of certificate.
3 SEX
Male
....
3 AGE
PARENTS
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
particular kind of work ...
4 COLOR OR RACE
White
5 SINGLE
MARRIED,
WIDOWED, Married
OR DIVORCED
(Write the word)
& DATE OF BIRTH
July 24
(Month)
(Day)
1
(Year)
$ OCCUPATION
(a) Trade, profession, or
Farmer
(b) General nature of industry. business, or establishment In which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Ayer Mas3
10 NAME OF FATHER George Livingston
11 BIRTHPLACE
OF FATHER
(State or country)
Tewksbury Mass
12 MAIDEN NAME
OF MOTHER
Phoebie Stone
13 BIRTHPLACE
OF MOTHER
(State or country)
Groton Mass
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mrs J.W.Livingston
(Address)
No Chelmsford Mass
Filed, Dec. 28, 1914 Edvard . Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
December 27 1914
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Dec 20.
, 1914 to
Dee 27
1914
that I last saw h alive on. Dee 26 191 4 and that death occurred, on the date stated above, at 3 a.m. The CAUSE OF DEATH* was as follows :
Hemiplegia
--
(Duration)
....... ... yrs.
mos.
7 de.
Contributory
(SECONDARY)
(Duration)
.............. yrs. .
... mos. ..........
... ds.
(Signed)
7 EVarney
M.D.
Dec 27, 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.
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 Edson Cemetry
DATE OF BURIAL Dec 29
.....
1914
20 UNDERTAKER youngour Blake
ADDRESS
72
....
(City or town.) Tlf death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Joseph W. Livingston
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
No Chelmsford Mass.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH No Chelmsford Mass (No. # 17 Gay St
St. :
Ward)
Registered No. 72
PERSONAL AND STATISTICAL PARTICULARS
185]
62
.yrs.
5
mos.
If LESS than
[ day ......... hrs.
ds.
Or ......... min. ?
..........
....
....
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," "Forcman," "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," unqualificd, 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.
1
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
Lowell. Mass. (No. 17 Chelmsford St. St. : Ward)
73
Lowell
(City or town.)
fif death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Rodney F. Hemenway
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford, Mass.
Registered No.
12
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
8 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word) Married
16 DATE OF DEATH
January 1.
191 5
(Month)
(Day)
(Year)
DATE OF BIRTH
July 5, 1858
(Month)
(Day)
1 (Year)
AGE
56
......... ..... yrs. 5 „mos. .. 27 ds. or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
SpecialAgent
(b) General nature of industry, business, or establishment in N. E. Tel. & Tel. co. which employed (or employer).
9 BIRTHPLACE
(State or country)
Massachusetts
10 NAME OF
FATHER
William w. Hemenway
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Massachusetts
12 MAIDEN NAME
OF MOTHER
Mary 0. Clapp
13 BIRTHPLACE OF MOTHER (State or country)
Massachusetts
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mrs. Edith M. Hemenway
(Address)
Chelmsford, Mass.
15
Filed Jan. 4, 191 5.
.. REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
.,
191.
....... , to
191
.......
that I last saw h ..
alive on ...
191
..... ,
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Disease of the Heart
( Acute Dilatation)
.(Duration) .
............ yrs.
ds.
Contributory
(SECONDARY)
.(Duration)
................ yrs. ...
... mos ..
.ds.
(Signed)
J. V. Meigs
M.D. Jan. 2, 191 5 (Addres) ... 160 Verrik St.
* If death followed injury or violence the certificate of death mast-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 Jan. 5, 191.5
"vWEUrge W. Healey
Max8.
..........
MARGIN RESERVED FOR BINDING
Male
White
If LESS than
I 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, c. 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, ctc. 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," unqualificd, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Careinoma, Sar- coma, etc., of .. .... .(name origin: "Cancer" is less ........ definite; avoid use of "Tumor" for malignant ncoplasms) ; 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," "Hcart failure,". "Haemorrhagc," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia'," "Weakness," etc., when a definite disease can be ascertained as the causc. 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 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
4. Deaths under circumstances unknown, as A person found dead, ctc.
{
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
1 PLACE OF DEATH Chelmsford 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE SEX 4 COLOR OR RACE 2 ' DATE OF BIRTH Low. May ....... (MonthY , AGE 78 8 OCCUPATION (a) Trade, profession, or particular kind of work ...... (b) General nature of industry, business, or establishment in which employed (or employer). 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 .... ... yrs. ...... .... mos. 20
5 SINGLE,
-MARRIED
WIDOWED.
of Widowed
(Write the word)
# 15 18.36
1/13-
17
......
(Day)
(Year)
If LESS than 1 day ......... hrs.
or ........ min. ?
Por
Housekeeper
at home
9 BIRTHPLACE
(State or country)
Dorchester Mass
10 NAME OF
FATHER
John Clogstino
11 BIRTHPLACE
OF FATHER
(State
country Goffstown N.H.
12 MAIDEN NAME
OF MOTHER
Mary Lowe
13 BIRTHPLACE
OF MOTHER
(State or country)
Dorchester
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Velma Hildretti
16 Filed Jan 5, 1915 Siwahid . Rolling ......... · REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jan 4
(Month)
(Day)
1915
(Year)
....
-
n
I HEREBY CERTIFY that I attended deceased from
Rac. 30
.... 1914, to
Jan 4
1910
...
that I last saw h & alive on far 4
.... .
191
...... ,
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Bronchitis
-
-
-
(Duration).
..........
.. yrs.
mos.
ds.
·
Contributory ...
(SECONDARY)
.. (Duration)
.......
...... yrs.
.. mos.
.ds.
(Signed)
Howard rfcwith
.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
In the
of death
yrs.
. mos.
... ds.
State .....
yrs.
... mos.
ds
.......
....
Where was disease contracted,
if not at place of death ?.
Former or
usual residence.
T
....
19 PLACE OF BURIAL OR REMOVAL
Forefathers Cem
DATE OF BURIAL
Law6
195
-
20 UNDERTAKER
ADDRESS
Walter Serham Thelma.
44
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No Chilleriec)
......
St. :......
........... Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
V
Mary ann
Hildreth
Maritlelogstons Berg. M. Hildreth
.....
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
-
7
.,
.
M.D.
Jan 6, 1915 (Address) Hymario Of
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
....
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 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
North Chilsford No. Con Church & Medellin
........ ..
John's Arany O Welche.
St. ;
Ward)
(City or town.) fIf death occurred in a hospital or institution, give its NAME ·nstead of street and number.]
2 FULL NAME [If married or divorced woman or widow/ give maiden name, also name of husband.] @RESIDENCE Cont Chauch & Michellesey Registered No. MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
1
If LESS than
1 day ......... hrs.
or ......... min. ?
at Anie
9 BIRTHPLACE
(State or country)
Jewell, Mais
10 NAME OF
FATHER
Michael Welche
11 BIRTHPLACE
OF FATHER
State of countrylaval
12 MAIDEN NAME
OF MOTHER
Mayanet Luelue
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
18 Filed ... Jan. 6. 1915 Edward& Rollom
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
1
... ,
(Year)
Dce /3
.... .
1914 to many 5
19152
.....
that I last saw him alive on.
19100
,
and that death occurred, on the date stated above, at 10.00 m.
The CAUSE OF DEATH* was as follows :
Myo carditis
.
ds.
(Duration) 2 yrs.
mos.
.
Contributory
(SECONDARY)
....
.
(Signed)
Fi Janney
... (Duration)
yrs.
.mos.
ds.
-
M.D.
·
* 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
In the
RECENT RESIDENTS).
At place
of death
......... yrs. ............ mos. ..........
... ds.
State ...
ds ..
Where was disease contracted,
......... yrs. .. mos. .... If not at place of death ?. Former or ....... usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL StPatrickstund Jau 8
.....
19/15
20 UNDERTAKER
ADDRESS 458 Goles
.
.
16 DATE OF DEATH
(Month)
.......... }
.....
(Year)
(Day)
5th
1915
3
75 N. Clalus.
' COLOR OR RACE
{ 5 SINGLE
$ SEX
Female White
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
(Month)
(Day)
7 AGE
18 y
& OCCUPATION
(a) Trade, profession, or
particular kind of work ....
.......
(b) General nature of industry,
business, or establishment in
which employed (or employer) .....
PARENTS
18 BIRTHPLACE
OF MOTHER
(State or country}
(Informant)
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
.......
.......... yrs.
... mos.
.... ds.
4
-
-
1918
(Address)
......
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 agc. For many occupations a single word or term on the first line will be sufficient, e. g., حيف
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 Housc- kcepers 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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