USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 22
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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.
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 Massariutsetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH North Chrehusar deNatrase
St. :...
......
...... ... Ward)
(City(or town.) fif death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
Oranna E. Howard
[If married or divorced woman or widow
give maiden name, also name of husband.]
Oranna C. allber tel & Forward
@RESIDENCE
No Chelundand mass
Registered No.
12
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Demale
4 COLOR OR RACE
whats
5 SINGLE
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
Manud
6 DATE OF BIRTH
July 20
-1855,
00
(Month)
(Day)
(Year)
7 AGE
59
5
.yrs ..
....
mos.
ds,
& 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)
linee mass
10 NAME OF FATHER James G. allbee
PARENTS
11 BIRTHPLACE OF FATHER (State or c Chesterfield Art .
12 MAIDEN NAME
OF MOTHER
Sarah Jours
18 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address) N Estrelandand Mass
16
Filed. That. 1 1915 Edward & Robbing
REGISTRAR
17
195 to
.....
I HEREBY CERTIFY that I attended deceased from
Jazy 2 B
.,
.......
....
July 27
1915~
If LESS than I day ... hrs. that I last saw h ~~ alive on. July 26 1915 .... and that death occurred, on the date stated above, at 2329 m. or ......... min. ? The CAUSE OF DEATH* was as follows :
-
(Duration)
... yrs. ....
1
.... mos.
ds.
Contributory ..........
(SECONDARY)
.......... (Duration) ... 2
mos. „ds.
loss 4 yrs
M.D.
(Signed)
July 27,
1910 (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).
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
DATE OF BURIAL
....
1915
20 UNDERTAKER Maingorge Blake
ADDRESS
33 Puscorte
....
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
Get 27-1915.191.
.....
(Month)
(Day)
(Year)
....
---
.... y
MARGIN RESERVED FOR BINDING
important. See instructions on back of certificate.
84 No Ctuluifand ......
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 naturc 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 necd 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.
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
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Proceder
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
Sevenden
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .
(Address) H. Chelmsford
15
Filed_
Mar. 3. 1915 Edward Y. Problem
....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
2.
25
G
...
...
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from Dea 25 , 1913 Ter 28 1915 .... . to ............... that I last saw her alive on. Feb 28 ... 1910 and that death occurred, on the date stated above, at 0,30Pm The CAUSE OF DEATH* was as follows :
Cinbasis of Luvas
Heart Queres
.. (Duration) .
.... yTS.
mos.
ds.
Contributory ...
.... (SECONDARY)
.. (Duration)
9
mos.
ds.
yrs.
Jament Hohan
M.D.
(Signed)
Mars, 1005
(Address) No 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).
At place
of death
.yrs.
. mos.
In the
ds.
.mos.
.ds ........
State ............ yrs.
.........
....
If not at place of death ?.
Where was disease contracted,
Former or usual residence.
19 PLACE OF BURIAL ØR REMOVAL Weer Coffret
DATE OF BURIAL
Next Chelin fund Mich 3
..........
1915
20 UNDERTAKER
Walter Derhan
ADDRESS
hans Chelmsford .
(Ciey or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME C ma Soplica Carlson
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Heat Chickensfond, Mais
PERSONAL AND STATISTICAL PARTICULARS
& SEX
7.
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
WIDOWEDJ
OR DIVORCED
(Write the word Uvedl
" DATE OF BIRTH
10
(Month)
(Day)
1873
(Year)
TAGE
42
.... yrs.
8
mos.
18
ds .
If LESS than { day .......... hrs.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
at home
(b) General nature of industry, business, or establishment in which employed (or employer) ...
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
YPLACE OF DEATH
Mest Chelmsford
(No.
Wilson Lane
St. . *
Ward)
Jeeling Carlson, AnnaS. Even
Registered No. 13
85
Chelmsford
.....
9 BIRTHPLACE
(State or country)
Sweeder
10 NAME OF
FATHER
Carl Enson
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 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 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.
1
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1915.
CITY OF BOSTON.
FULL NAME
JOSEPH MERRILL FLETCHER
Registered No.
1767
Place of Death l and Residence
Boston
HOME FOR AGED COUPLES
1915.
Age
years
4
months
19
days.
14
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
WID.
Maiden Name
S
RAR'S
UT PATRIEAS, SIT DEUN Primary: ( Duration)
SEFICE
BOSTONIA CONDITAA
TISREGIMIE DONATA A BOSTO
N. MASS
Contributory : ( (Duration) ARTERIO-SCLEROSIS - YRS
(Signed) E. N. LIBBY M.D.
FEB. 19 1915 SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Usual Residence
CHELMSFORD
Filed
FEB.26 1915.
A true copy. Attest :
Registrar.
MARGIN RESERVED FOR BINDING.
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from
1915, to
1915 that to the best of my knowledge and belief death occurred, on the date stated above, and that the CAUSE OF DEATH was as follows :
Husband's Name
Birthplace
Name of Father
----- FLETCHER
Birthplace of Father
CHELMSFORD
Maiden Name of Mother
-
Birthplace of Mother
CHELMSFORD
FARMER
Occupation
Informant
Place of Burial or removal
CHELMSFORD
F.L. BRIGGS
Undertaker
FEB.19
86
Date of Death
86
FRAC. LEFT HUMERUS - 5 DYS
CHELMSFORD
CITY REGI
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
8 SEX & OCCUPATION 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
1 PLACE OF DEATH
2 FULL NAME [If married or divorced woman or widow give maiden name, algomame of husband.1. @RESIDENCE
Paradieselt no Chelmsford ed
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
tingle
" DATE OF BIRTH
(Month)
(Day)
18.73 (Year)
7 AGE 1/2 -
.... If LESS than I day ......... hrs.
yrs. mos. ds.
Or ......... min. ?
(a) Trade, profession, of particular kind of work.
Registered Nurse
(b) General nature of industry, business, or establishment in which employed (or employer).
God's nehmeford, Mass.
NO NAME OF FATHER InFenomen
11 BIRTHPLACE OF FATHER (State or country)
112 MAIDEN NAME
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Addres) ochelmapa Rua
18 Filed Mar. 8 95 Idubuff E. Ellis aast. REGISTRAR
........
16 DATE OF DEATH
3
(Day)
6
1916
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Mar 1, 1916, to
Mar 1, 1915
that I last saw her alive on
May 6, 1918.
and that death occurred, on the date stated above, at 6:45 m.
The CAUSE OF DEATH* was as follows :
Carcinoma Breast
(Duration)
9
yrs.
mos.
da.
Contributory.
(SECONDARY)
(Duration)
... yrs.
.... mos.
ds.
(Signed) Mary .........
2015 (Adress) No. 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).
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. ....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL It Patrick's than 8
191
ADDRESS
no thelmelor 57
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Catherine amenancy ........... .
St. ;.................... Ward)
15
MEDICAL CERTIFICATE OF DEATH
(Month)
--
....
.......
M.D.
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 laborcr, 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); Mcasles; 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," Matrim "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 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.
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
Chelmsford
.. (No
north Road
Jerome
St Brown
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford mass
Registered No.
16
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male white
{ COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
$ DATE OF BIRTH
May
7. 1849
(Month)
(Day)
(Year)
3 AGE
If LESS than
1 day ......... hrs.
mos.
or ......... min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
Harmer
(b) General nature of industry,
business, or establishment In
which employed (or employer).
Farmer.
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
Baidgham Brown
11 BIRTHPLACE
OF FATHER
(State or country)
wwwich it
12 MAIDEN NAME
OF MOTHER
Mercy Loveland
18 BIRTHPLACE
OF MOTHER
(State or country)
Nowych W-
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Tvaro mary E. Brown
(Address)
Chelmsford maso
16 Filed_ Mar 15 1915 Hilbut E. Ellis ant. REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
19 !....... 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 :
Pneumonia (So thought to be by
the family-) no physician in attendance
Christian Secontin Uischauen !.
.....
ds.
Contributory
(SECONDARY)
Q (Duration).
yrs.
.... mos. .
................ ds.
(Signed)
Autre T. cobori (igh, Broad of Health) M.D.,
mar. 13. 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
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. .......
DATE OF BURIAL
19 PLACE OF BURIAL OR REMOVAL Land.
Forefathers
Chet
2 Cemetery Mach 15. 1915.
20 UNDERTAKER
Gro. Malealey
ADDRESS
79 Branch St.
12.
(Month)
(Day)
1915
(Year)
16 DATE OF DEATH
march
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