USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 28
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culosis of lungs, meningcs, peritonacum, etc., Carcinoma, Sar- coma, etc., of .......... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pncumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia,". " An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Scnile," cte.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite discase 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 inust 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 dcath upon the street, or one supposed to be due to Alcoholism, etc
4. Deaths under circumstances unknown, as A person found dcad, 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
Lowell Mars. (No.
St. John's / Hospital.
.St. ;
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Catherine Jones Catherine Mc Glinchey-Georg D. Jones 35
{If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
North Chelmsford
Macally
Registered No. 2 984
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
termale White
{ 5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) Married
6 DATE OF BIRTH
876
17
(Month)
(Day)
(Year)
7 AGE
39
.yrs. mos. .ds.
or ......... min. ?
S OCCUPATION
(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)
W. Chelmsford Mars.
PARENTS
12 MAIDEN NAME
OF MOTHER
Ellen Eagan
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
George Jones
) ....
(Addrese)
Ind Chelmsford Mass
16 Marg
Filed
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
February
195
(Month)
(Day)
(Year)
I HEREBY CERTIFY that Iattended deceased from
February 27, 1915, to.
February 28 1915
that I last saw her alive on
11
28 195 and that death occurred, on the date stated above, at fm. The CAUSE OF DEATH* was as follows : Lobar Ineumonía
(Duration)
.. yrs.
mos. ds.
Contributory (SECONDARY)
.(Duration)
... yrs.
.... mos.
................ ds.
(Signed)
Thomas4. 6. Prison, M.D.
Feb. 28, 1915 (Address) St Johns Hoop Lowell
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
IS 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
DATE OF BURIAL
St. Patrick Cemetery Mar. 2
ADDRESS
20 UNDERTAKER
fait. 6' DonnellSons Lowell
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
10 NAME OF
FATHER
James McGlinchey
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
usband
108
Lowell .......
MARGIN RESERVED FOR BINDING
If LESS than
I day, ........ hrs.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precisc 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 "Laborcr," "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- Icepers 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, ctc. 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 discase. Examples: Cercbro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobur 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 discase; 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" (mercly symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "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.
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
(No Central Sq.
St. ;.................... Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Qua May Folloff
abner
....
Registered No. 36
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
abril
30
(Month)
(Day)
19| J
(Year)
....
17 I HEREBY CERTIFY that I attended deceased from apr.20, 1915, to abr. 30, 1915
that I last saw her alive on. af. 30 . 1915 and that death occurred, on the date stated above, at /1.30P.m. The CAUSE OF DEATH* was as follows :
Veratral embolism
.... (Duration)
..... yrs.
...
.........
mos.
ds.
Contributory ...
myocarditis
(SECONDARY) Seperde 44ans
............ yrs.
.........
... mos. ............... ds.
(Signed)
.........
Amasastoward
M.D.
May 3, 1915 (Adres).
Chelmsford Mass.
* 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
Forefathers Cemetery
Chelmsford mager
DATE OF BURIAL
May 4, 1915
20 UNDERTAKER
Hatten Berham
ADDRESS
Chelmsford
Filed. 0
REGISTRAR
......
............
1 PLACE OF
DEATH
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
& SEX
4 COLOR OR RACE
5 SINGLE
MARRIED,
Hidro
WIDOWED,
OR DIVORCED
(Write the word)
white
Herale
" DATE OF BIRTH
June 8 186%
..
(Month)
(Day)
(Year)
! AGE
If LESS than
I 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) ..
9 BIRTHPLACE
(State or country)
Lowell
10 NAME OF
FATHER
John 6. Hobbs
11 BIRTHPLACE
OF FATHER
(State or country)
Eppingham Mitt.
12 MAIDEN NAME ·
OF MOTHER
Caroline Johnson
PARENTS
18 BIRTHPLACE
OF MOTHER
(State or country)
Haverhill U.H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Uno De. Hobbs
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.
47 yrs. 10
... mos.
22
ds.
(Address)
Chelmsford
16
May 3, 1915 Edward & Gabbana
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
............
109 Chelmsford
2
......
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 3 AGE 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 ....
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Cast- Chelmsford No.
Carlton arts ...
Ward)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
Devras R. Goldwell
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
.......
@RESIDENCE
East
Chelmsford mass
Registered No.
37
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
Female white
1 5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
...
(Month)
(Day)
(Year)
'DATE OF BIRTH
may
32.0
19.13
17
I HEREBY CERTIFY that I attended deceased from
(Month)
(Day)
(Year)
Apr 30
195, to may 2
If LESS than
I day ........ hrs.
......... 1915-
that last saw hewalive on hry
1915-
1
11 mos. 13 ds.
and that death occurred, on the date stated above, at 5-A m.
.. yrs.
or ......... min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
none
The CAUSE OF DEATH* was as follows :
Capilary Bronchite
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
......
None
....
º BIRTHPLACE
(State or country)
East Chelmsford
10 NAME OF
FATHER
James W. Goldwell
11 BIRTHPLACE
OF FATHER
(State or country)
nova Scotia
fertig
12 MAIDEN NAME
OF MOTHER
ada Henderson.
18 BIRTHPLACE
OF MOTHER
(State or country)
nova Scotia
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mrs ada Coldwell
(Address)
East Chelmsford
Filed.
May 5, 1915 Edward J. Rotting
REGISTRAR
... (Duration)
... yrs.
...
.. mos.
5- ds.
Contributory ...
Sichly since birth
(SECONDARY)
(Duration)
... yrs.
mos.
ds.
M.D.
may 4, 1913 (Address).
276 West Really
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
In the
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death
yrs.
.. mos.
ds.
State ...
.... y.s.
.mos.
as .............
Where was dlsease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Westlawn Cemetery May 5, 1915.
20 UNDERTAKER
GromHealey
ADDRESS
79 Branch 8%.
.......
(Signed)
Forti Smecter
...... ,
110 Chelmsford (City vrtown.)
PERSONAL AND STATISTICAL PARTICULARS
.........
10 DATE OF DEATH
may
2.
191.5
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- keepcrs 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 homc. 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. - Namc, 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 usc 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, ctc.
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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
No Chelmsford
1 PLACE OF DEATH
No Chelmsford Mass
.. (No
St. :
Ward)
(City or town.) Tif death occurred In a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Mary Howard
[If married or divorced woman or widow
give maiden name, also name of husband.] Mary Taiday
@RESIDENCE
North Chelmsford
Calvin Howard
Registered No. 38
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
Female
' COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
Widow
OR DIVORCED
(Write the word)
(Month)
(Day)
(Year)
· DATE OF BIRTH
Aux 18
(Month)
1829
I (Year)
7 AGE
If LESS than
1 day ..
...... hrs.
85
....... yrs .....
8
mos ..
ds.
or ......... min. ?
* 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)
Groton Vermont
10 NAME OF
FATHER
James Taisey
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
Ruth Darling
1$ BIRTHPLACE
OF MOTHER
(State or country)
Groton Vt
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Henry .E. Howard
(Address)
North Chelmsford Mass
16
Filled. may 12 1956board S Rotting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
1
I HEREBY CERTIFY that I attended deceased from
april 28
May 10
19/02
19/0, to
...
.......
that I last saw h- alive on.
mary 9 -
and that death occurred, on the date stated above, at 3 a.m.
The CAUSE OF DEATH* was as follows :
Broncho- pneumonia
(Duration)
... yrs.
8
mos.
ds.
Contributory
(SECONDARY)
(Signed)
JE Varney
(Duration)
........... yrs. ..............
.... mos.
.... ds.
M.D.
May 10; 1915 (Addres
JEflaney
* If death followed injury or violence the certificate of death must be made ont 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
Riverside Cemetry
No Chelmsford
DATE OF BURIAL
May 12, 1915
20 UNDERTAKER
young and Blake
ADDRESS
33 PuccessSt.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
.......
......
...... ........
....
(Day)
1$ DATE OF DEATH
May 10 2935
191
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 Nonc.
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