USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 27
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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)
..........
[If married or divorced woman or widow
give maiden name, also name of husband.]
........
Ivey A Griffin
Samuel K. Johnson
@RESIDENCE
·Chelmsford Centr
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
April
25
1915
191
(Year)
(Month)
(Day) .... ............
17
I HEREBY CERTIFY that I attended deceased from
Www. 25, 1917 to
apr. 25 95
that I last saw h en alive on
ater 25
..... .
1915 and that death occurred, on the date stated above, at 2. 2:10 am.
The CAUSE OF DEATH* was as follows :
Ihreardial Degeneration
Senility
1
(Duration) [ ......... .... yrs.
.mos.
....... .ds.
-
Contributory ..
(SECONDARY)
................................................ ...........................................................................................
(Duration).
.... yrs.
.mos.
(Signed)
Antrung Scoloriar
M.D.
apr 25, 1915 (Address) Chilisford, Mass.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
16 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
.. yrs.
In the
. ......
... mos. ............. "
... ds.
State ............ yrs.
.......
.mos. .......
.................
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL No Andover Mass
DATE OF BURIAL
Apr 26
.....
1915
20 UNDERTAKER Young ( Blake
ADDRESS
Filed_
apr. 26, 1915 Janhat 6. Juli
REGISTRAR
104
Chelmsford Centr (City or town.) Tlf death occurred in a hospital or institution, give its NAME instead of street and number.]
1 PLACE OF DEATH
Chelmsford Centre
(No.
2 FULL NAME
Lucy A. Johnson
3 SEX
Female
' COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
White
· DATE OF BIRTH
January 30
1828
(Month)
(Day)
TAGE
87
& OCCUPATION
(a) Trade, profession, or
particular kind of work
At Home
......
(b) General nature of Industry,
business, or establishment In
which employed (or employer) ...........
$ BIRTHPLACE
(State or country)
Mathuen
Mass
10 NAME OF
FATHER
Alonzo Griffin
12 MAIDEN NAME
OF MOTHER
Lucy Sargent
PARENTS
13 BIRTHPLACE
OF MOTHER
Mathuen
Mass
(State or country)
(Informant) Annie I Chase
important. See instructions on back of certificate.
(Address)
Chelmsford Centre
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 ..
2
mos.
ds.
1
(Year)
If LESS than
I day .......... hrs.
Or ......... min. ?
........
11 BIRTHPLACE
OF FATHER
(State or country)
Mathuen
Mass
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Widow
Registered No. 32
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- molivc 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 diseasc. 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) affeetion 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," ete., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or misearriage, 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
12 MAIDEN NAME
OF MOTHER
Mary J. Macdonald.
13 BIRTHPLACE
OF MOTHER
(State or country)
P.E. Island.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Abner Hemlow
(Address) No. Chelmsford, Maes
15 Filed af. 27, 195 Jusbut E. Ellis aut REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
At hite
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Single.
6 DATE OF BIRTH
March 9.
(Month)
(Day)
1908
(Year)
AGE
If LESS than I day .......... hrs.
7 yrs.
... yrs. ..
1
.mos. ....
16
.. ds.
or ......... min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work.
School Boy
(b) General nature of industry. business, or establishment in which employed (or employer).
School Boy.
.(Duration)
.........
yrs. ..
.............. mos.
.......
.. ds.
Contributory (SECONDARY)
(Duration)
.... yrs.
.. mos.
ds.
M.D.
(Signed)
ah. 21, 1915 (Addres).
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death
yrs.
... mos.
ds.
State ...
.... yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence.
DATE OF BURIAL
19 PLACE OF BURIAL OR REMOVAL Riverade No. 8 helmefor April 27,195
20 UNDERTAKER
grom
ADDRESS
Healey 29 Branch5%
105 % Chalupallar:
Ward)
Town [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Carl F. Hcmlow
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Can yay theafield h.
Registered No. 53.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
april
24
(Month)
(Day)
1915
(Year)
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
accidental browning
1
(Torres Canal Www. Chalupad)
...
§ BIRTHPLACE
(State or country)
No. Chelmsford, Mack.
10 NAME OF
FATHER
Abner Hemlow.
11 BIRTHPLACE OF FATHER (State or country) Nova Scotia
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
Chelmsford
Ruth)
(No.
hours Canal
St.
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 matcrial 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. 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 (retircd, 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 usc of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, is indefinite); Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar coma, ctc., 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" (mcrely 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 discases resulting from childbirth or miscarriage, as "PUER- PERAL scpticaemia," "PUERPERAL peritonitis," ctc. 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., scpsis tetanus) may be stated under the head of "Contributory."
Cases for the Medical Examiner's. - 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.
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
(City or town.)
Chelmsford CondiviNo ...
Warren Give-
JIf death occurred in
St. :
a hospital or institution,
Ward)
give its NAME instead
of street and number.}
Still Born (ayotte)
2 FULL NAME
14
....
[If married or divorced woman or widow
give maiden name, also name of husband.]
......
@RESIDENCE
Registered No.
Warren
live
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
(Day)
-
Male
5 SINGLE
MARRIED,
Single
WIDOWVED
OR DIVORCED
( Write the word)
16 DATE OF DEATH
March
1
191.
(Year)
(Month)
· DATE OF BIRTH
Mande
-
1975
17
J HEREBY CERTIFY that I attended deceased from
(Month)
(Day)
(Year)
Mar 1, 1915, to.
mai 1
1915
3 AGE
that I last saw hamalive on.
...... .
If LESS than
I day ......... hrs.
..........
...... .
and that death occurred, on the date stated above, at ..................... m.
1
yrs.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ...
...........
The CAUSE OF DEATH* was as follows :
never -
191
. .....
mos.
ds.
or
.......... min. ?
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Chemford Mars.
... (Duration).
........... yrs.
................ mos.
.ds.
Contributory
...
(SECONDARY)
10 NAME OF
FATHER
? (Duration) .......
Eprima aufatto
.. yrs. ..............
... mos. ................ ds.
Aula
wy G. colonial.
(Signed)
M.D.
11 BIRTHPLACE
OF FATHER
(State or country)
Canada
March 2 015 (Address).
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
12 MAIDEN NAME
OF MOTHER
Clarence Regis
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
PARENTS
At place
of death
yrs.
mos.
ds.
State.
In the
yrs.
.mos. ........
... ds .............
13 BIRTHPLACE
Where was disease contracted,
If not at place of death ?.
OF MOTHER
(State or country)
Canada -
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Eprime aujatte
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
............
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
St Joseph chelmsford March. 2
(Address)
Warren Que chempero antes
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
......
Former or
usual residence.
......
16 File Was 2 195 Ilchul E. Ellis
....... aut. REGISTRAR
5 .
1915 -
20 UNDERTAKER
d.
albert
ADDRESS
171 arkenat
Ed.g. Ra
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 (rctired, 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, Suicidc, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
1
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
1 PLACE OF DEATH
Lowelf Mark
(No.
...... St. Johne dospital
St. ;............ Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford Mass
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
February
4
191 9
.....
(Month)/
(Day)
(Year)
6 DATE OF BIRTH
1860
17
(Year)
7 AGE
1
514
....
... yrs. mos. i.ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
......
Laborer
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE
(State or country)
M. Chelmsford Mass
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
dunasboro Mass.
12 MAIDEN NAME
OF MOTHER
ar
ah Lovett
18 BIRTHPLACE
OF MOTHER
(State or country)
Meredith n. H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Geo. W. Blood
(Address)
Stoneham Mars
16 Filed deb 9, 1915
REGISTRAR
....
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 :
accident
(dall from ladder)
(Duration).
... yrs.
.mos.
.ds.
Contributory ....
Compound Fracture of Ribe
.....
(SECONDARY)
operation
n of Lung (Duration)
.yrs.
mos.
ds,
(Signed)
0 r meigo.
M.D.
Feb. 6, 1915
(Address) 160 Mehrim
mada ste
* 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.
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 Riverside Cem Chelmsford.Feb. "
191 52
20 UNDERTAKER
young + Blake
ADDRESS
Lowell.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
3 SEX
male
4 COLOR OR RACE
White
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)'
a) Widowed
(Month)
(Day)
107
Lowell ....
Idenry L. Blood
34
I HEREBY CERTIFY that I attended deceased from
10 NAME OF
FATHER
Nathaniel Blood
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 linc 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 laborcr, 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- CASE 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-
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