USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 21
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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: Ccrebro-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, ctc., Carcinoma, Sar coma, etc., of. (name origin: "Cancer" is less definite; avoid usc of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ctc. 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," "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 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.
i
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
2 FULL NAME 8 SEX Hemale YAGE 2 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. 15 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
1 PLACE OF DEATH Chelmsford (No So Chelinford Village
St. :....
............ Ward)
Thelma Frances Burton
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE So Chelmsford have
....
8
Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
Jan 31, 1915 +
to
Feb. 8
1915
that I last saw him alive on.
1915
........
and that death occurred, on the date stated above, at .. ....... .m.
The CAUSE OF DEATH* was as follows :
,
Deplitheria-
Insommagastric Sanalysen
(Duration)
.... yrs.
mos.
ds.
Contributory ... ...................... ....
(SECONDARY)
.... (Duration)
„yrs.
mos.
ds.
(Signed)
Arthur , Scobona
M.D.
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.
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 HartPond Cens
DATE OF BURIAL
Heb 10
... 1915
-
(Address)
So Chelmsford
Filed Feb-10 , 195 Oderard . Bobbing
REGISTRAR
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
15 19/2
(Month)
(Day)
(Year)
If LESS than
I day ......... hrs.
4
.mos.
25 ds.
or ........ min. ?
9 BIRTHPLACE
(State or country)
Yeah Shokan n. Y.
10 NAME OF
FATHER
George E. Burton
11 BIRTHPLACE
OF FATHER
(State or country)
Cushing, Maine
12 MAIDEN NAME
OF MOTHER
Florence Cresswell
13 BIRTHPLACE
OF MOTHER
(State or country)
Matthaus, Eng,
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
1,E Burton
20 UNDERTAKER
Menhan
ADDRESS
Chelmsford
191.5
(Month)
(Day)
9
(Year)
· DATE OF BIRTH
Sept
4 COLOR OR RACE
white
PERSONAL AND STATISTICAL PARTICULARS
80 Chelmsford .... (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
...............
...
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber .
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. .(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical 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.
3 SEX Male 7 AGE (a) Trade, profession, or particular kind of work 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 77
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford Centre Mais
St. ;.
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Thomas Everett Chase
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford Centre Mass
Registered No.
9
PERSONAL AND STATISTICAL PARTICULARS
15 SINGLE,
MARRIED,
WIDOWED,
Widowed
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Ano 27 1837
(Month)
(Day)
1
(Year)
If LESS than
I day ......... hrs.
& OCCUPATION
President T.E. Chase & Son
Čo
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Newbury Mass
10 NAME OF
FATHER
George Chase
11 BIRTHPLACE
OF FATHER
(State or country)
New Hampshire
12 MAIDEN NAME
OF MOTHER
Susan A.Chase
13 BIRTHPLACE
OF MOTHER
(State or country)
Not Known
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Arthur A. Chase
(Address)
Chelmsford Centre Mass
Filed Feb. 13, 1915 Edward S. Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Feb 10 1915
...
(Month)
(Day)
191
(Year)
I HEREBY CERTIFY that I attended deceased from
17
Jan, 30
1915, to
Fab. 10
1915
that I last saw hMMM alive on
1
Epicb, 10
1915
..........
and that death occurred, on the date stated above, at ...
......
m.
The CAUSE OF DEATH* was as follows :
arteriosclerosis
Seft Haemplegia
(Duration)
mos.
ds.
Contributory ..
(SECONDARY)
(Duration)
) ................ yrs.
.......
mos,
ds.
(Signed)
Arthur I. Scotone
M.D.
Fint 1 2, 1915 (Address
Chilisford, mas.
1/1020
* 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 Mt Hope Cemetry Mattapan Mass
DATE OF BURIAL
Feb 13, 1915
.....
20 UNDERTAKER
Young and Blake
ADDRESS
33 PrescottIt
....
4 COLOR OR RACE
White
.yrs. 5 mos.
14
ds.
or ......... min. ?
81
Chelmsford ........
..
....
.......
... yrs.
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) 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 ("Pncumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- eoma, etc., of .. ........ ...... .. (name origin: "Cancer" is Icss 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 nced 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" (mercly 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.
3 SEX Female PAGE 8 OCCUPATION PARENTS 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 ..........
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford
(No
Park Road So Chelmsford
St. ;.......... Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME.
Sarah Quy Warte
[If married or divorced woman or widow give maiden name, also name of husband.1 Sarah a Colby, Ses Chraite
@RESIDENCE
So. Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Widow
$ DATE OF BIRTH Oct 6,18.30
(Month)
(Day)
1
(Year)
(a) Trade, profession, or
particular kind of work
at home
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Bow; n.H.
10 NAME OF
FATHER
Jesse Colby
11 BIRTHPLACE
OF FATHER
(State or country)
Bow, n. 7+.
12 MAIDEN NAME
OF MOTHER
Sally austin
13 BIRTHPLACE
OF MOTHER
(State or country)
Hooksett n.H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
a.F. waite
(Address)
So Chelimiford
Filed
Feb. 18, 1915 Edward & Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Fib
€
(Day)
15
1915
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Jan. 11
1915 to
Feb. 12th
1915
.....
that I last saw her alive on.
Jan 12
, 1915
and that death occurred, on the date stated above, at ..
9 a.m.
The CAUSE OF DEATH* was as follows :
Valvular dueau of heart.
....... ,(Duration)
... yrs.
mos.
ds.
Contributory.
Senility
.......
(SECONDARY)
.. (Duration).
.... yrs.
.mos.
ds.
(Signed)
Amara toward
M.D.
46. 15. 1915 (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).
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
Dumbarton Centros Cem Dumbarton n. H.
DATE OF BURIAL Heb 18, 1915
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
82 Chelmsford
...
Registered No.
10
...
(Month)
.. y
If LESS than 1 day ......... hrs.
84
re. 4
mos.
9
ds.
........ 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," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber .
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. ........ .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
St. :
Ward)
2FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Weet Chelmsford mare.
...
Registered No. 10
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
February 26
1915
(Month)
(Day)
(Year)
....
have curatigater
I HEREBY CERTIFY that I attended deceased from
the death of the deceased.
., 191
....... , to
that I last saw h. -alive on ......
and that death occurred, on the date stated above, at ...........
The CAUSE OF DEATH* was as follows :
natural causes presumably
dieease of heart
.....
...
.(Duration)
ds.
.. yrs.
.mos.
....
Contributory ..
(SECONDARY)
(Duration)
.yrs.
.mos.
ds.
(Signed)
Franck J. Bulleley
......
M.D.
Feb. 26 1915 (Address) ayer Mass
.....
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner. Medical Oxamer
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death.
... yrs.
... mos.
ds.
State ............ yrs.
..... mos.
In the
...........
.......
Where was disease contracted, If not at place of death ?.
Former or
usual residence ............
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Weet Bew. W.Chelmsford Feb. 28, 1915
20 UNDERTAKER
Walter Perham
ADDRESS
Chehusford
REGISTRAR
83 Westford (City or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
1 PLACE OF DEATH
Westford
.(No.
Thomas Freer
PERSONAL AND STATISTICAL PARTICULARS
& SEX
male
4 COLOR OR RACE
white
5 SINGLE
MARRIED,
WIDOWED, Widowed
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
If LESS than
[ day .......... hrs.
70
.. yrs.
.... mos.
.... ds.
or ......... min. ?
8 OCCUPATION
Stone Gutter
(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)
") Leicestershire Eng.
10 NAME OF
FATHER
C
trees
11 BIRTHPLACE
OF FATHER
(State or country)
England
12 MAIDEN NAME
OF MOTHER
Unknown
PARENTS
18 BIRTHPLACE
OF MOTHER
England
(State or country)
16 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Frank J. Bulleley m.D.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
....
important. See instructions on back of certificate.
(Address)
ayer mare. 0
16
Filed Feb. 26, 1915 Charles & Heiltseth
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
.....
1844
491 ...
........ !
ds.
......
....
J
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 (6) 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 occupation whatever, write None.
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