USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 20
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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- acmia" (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.
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 4 8 SEX 4 COLOR OR RACE Female · DATE OF BIRTH .... (Month) . " AGE 8 OCCUPATION (a) Trade, profession, or - particular kind of work ............. ...... (b) General nature of Industry, business, or establishment in which employed (or employer) ..... 10 NAME OF FATHER PARENTS 13 BIRTHPLACE 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. mos.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH Both Chelux ford Mas .(No. 4 amberat
Cheles ford
...
.....
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
...
aubert It Anth Chalet Registered No.
PERSONAL AND STATISTICAL PARTICULARS
| 5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
kugle
15
19x5
17
(Day)
(Year)
If LESS than
[ day ......... hrs.
17 d
.ds.
or ......... min. ?
9 BIRTHPLACE
(State or country)
Anth Chelus God
5
11 BIRTHPLACE
OF FATHER
(State or country)
England
12 MAIDEN NAME
OF MOTHER
any those
England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 1
(Informant)
Filleaus mi Can Niother
(Address) 4 awheat It. A Chamaford
Filed Feb. 2, 1995 - Edward . Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
I HEREBY CERTIFY that I attended deceased from Sony 17, 1915,
1915
that I last saw h ~ alive on ... ,1916 .... and that death occurred, on the date stated above, at 6 :30 a.m.
The CAUSE OF DEATH* was as follows :
polisencan tuberculosis
(Dura nation )
.. yrs.
mos.
................
... ds.
Contributory
(SECONDARY)
(Duration) ..
.yrs.
.......
mos. ..............
.. ds.
(Signed)
M.D.
July (, 1915 (
Norte 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).
In the
At place
of death
yrs.
... mos. ........
ds.
State ............ yrs.
..... mos. ............
d ..............
Where was disease contracted, If not at place of death ?.
................................................................ Former or usual residence. ...... ....
19 PLACE OF BURIAL OR REMOVAL
Of Cating Century
Thuy'
DATE OF BURIAL
teh 2
191
........
20 UNDERTAKER
ADDRESS
324 Mayor OF.
-
34
....
(Month)
(Day)
1915- (Year)
4
St. :
. „Ward)
....
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- motivc 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 cxamples: (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," "Senilc," 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, ctc.
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
....
(City or town.)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Mildred Grace Buchanan
[If married or divorced woman or widow give maiden name, also name of husband. @RESIDENCE No. Chelmsford masa
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
male white
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
Angle
& DATE OF BIRTH
Jeho IN8 1898.
..
(Month)
(Day)
(Year)
? AGE 16 yrs. 5 mos 3ª
„ds.
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)
ska Michaelud
10 NAME OF
FATHER
Female Buchanan
PARENTS
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE
OF MOTHER
Prince Edward file
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)/
(Address) No Metanimal
16 Filed Feb. 9 1915 Edward & Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
L
3
1
191 5
............
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
July 5
1914, to
.,
m.
that I last saw he alive on
July 7
1915
1915
.. ,
and that death occurred, on the date stated above, at 10
The CAUSE OF DEATH* was as follows :
Pulmonary tuberculosis
.(Duration)
1
.. yrs.
.. mos.
ds.
Contributory .. (SECONDARY)
(Duration)
... yrs.
mos.
ds.
(Signed)
F & Varney
M.D.
July. 8.
. 1915 (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 ..
.......
In the
... 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
Leb 99, 1914
UNDERTAKER
ADDRESS
Hahn A Wembecky Hlou het
77
I PLACE OF DEATH North Chelmsford No. .
St. :
;...................
Ward)
Registered No.
5
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
...
....
......... ........
......
11 BIRTHPLACE OF FATHER (State or country)
If LESS than
t day ......... !
...... hrs.
1
:
-----
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 - 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.
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-
1
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 duc 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.
& SEX Male PAGE 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
..........
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
6
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
/ (Month)
(Day)
(Year)
$ DATE OF BIRTH
San
23
(Month)
(Day)
If LESS than
I day ......... hrs.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
L
9 BIRTHPLACE
(State or country)
Chelmsford
10 NAME OF
FATHER
William Reid
11 BIRTHPLACE
OF FATHER
(State or conntry)
Ireland
12 MAIDEN NAME
OF MOTHER
Mary B Taylor
18 BIRTHPLACE
OF MOTHER
(State or country)
Halifal U.S.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Um Reid
(Address)
Chelmsford
16 Filed __ Fieb. 8 . 1915 Edward S Roff ing.
....
REGISTRAR
17
I HEREBY CERTIFY that Lattended deceased from
Jan. 23
.. 1915 to
1915
that I last saw have alive on.
1
1915.
.... .
and that death occurred, on the date stated above, at.
m.
V
The CAUSE OF DEATH* was as follows :
attuna
(Duration)
.........
.yrs.
mos.
1.5 0
„.ds.
Contributory
(SECONDARY)
....... (Duration)
.... yrs.
................ mos.
................ ds.
(Signed)
lau 8.
..........
1915 (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 ............ yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?.
...... .... Former or usual residence .. ........
19 PLACE OF BURIAL OR REMOVAL Het Pine Ridge Cens
DATE OF BURIAL
1915
20 UNDERTAKER
W. Parham
ADDRESS
Chelmsford.
... ,
7
1915
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
St. :
Ward)
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
chelmsford
78
1 PLACE OF DEATH
Chelmsford
(No.
High Sr.
2 FULL NAME
Russell Taylor Reid
1915
(Year)
C
... yrs.
0 mg
Mos. 15
.
....
colonia
.... ,
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 (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 rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinitc); 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.
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. Littleton Road of.
John The Gunners 2 FULL NAME [If married or divorced @roman or widow give maiden name, also name of husband.] @RESIDENCE 4 Puan 39 Tummer X
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Malo.
4 COLOR OR RACE
which
6 DATE OF BIRTH
1879
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day, ........ hrs.
.mos.
ds.
or ......... min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work.
Labour
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Fuland
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Viland
12 MAIDEN NAME OF MOTHER . Tar mo Callegan
13 BIRTHPLACE OF MOTHER (State or country) Rulandil
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
My Theresa MiJumet
(Address)
16 Filed tel. 10, 1915 Edward . Robbing
REGISTRAR
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
accident (Crush fechar)
by call of overhanging Early 1
.mos. ds. .(Duration) ... yrs.
Contributory
(SECONDARY)
.(Duration)
.......
...... yrs.
.............. mos.
ds.
(Signed)
AV. Mais
...
M.D.
(Address) 16 attentiontil
...... 1914
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).
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
Sopotuchy
DATE OF BURIAL Feb. 11.1915
20 UNDERTAKER
ADDRESS 176 Lacham Ex.
--
.79 Chelmsford
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
0
1915
....
(Month)
(Day)
(Year)
.
35-
...... yrs.
& SINGLE, MARRIED, , WIDOWED, OR DIVORCED (Write the word) 3.
MARGIN RESERVED FOR BINDING
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 cach 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) Salcs- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Houscwork, or At home, and children, not gain- fully employed, as At school or At home. Carc 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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