USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 29
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Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- 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 ascertaincd 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, ctc.
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
(No
Frederick Bailey
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
COLOR OR RACE
White
·SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
· DATE OF BIRTH
Oct
841
(Month)
(Day)
(Year)
7 AGE
If LESS than ! day ......... hrs.
73
......
.............. yrs ..
7
mos.
16
ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work,
.............
Retired Drugjest
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
Retired
9 BIRTHPLACE
(State or country)
W. Andover, Mass.
PARENTS
12 MAIDEN NAME
OF MOTHER
Miguel Rogers
13 BIRTHPLACE
OF MOTHER
(State or country)
Mars
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mrs. Carrie M. Bailey
(Address)
Chelmsford Mazo
15 Filed May 19, 1915 Oderard Saltthing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
may
(Month)
(Day)
18
1915. (Year)
17
I HEREBY CERTIFY that I attended deceased from
aug. 27
. 1915, to.
May 18, 1915
..........
that I last saw him alive on.
1
May 18'
.... .
, 1915
and that death occurred, on the date stated above, at 410.
.m.
The CAUSE OF DEATH* was as follows :
autointorrication.
Intestinal Paresis.
(Duration)
.... yrs.
mos.
ds.
Contributory ..
(SECONDARY)
{Durationy
... yrs.
.mos.
ds.
(Signed)
Arthur J Scoloria
M.D.
may 18, 1918. (Address)
Chehusford, 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).
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 Teurs burs Mags
DATE OF BURIAL
May 21, 1915
20 UNDERTAKER
Geo. W. Healer
ADDRESS
79 Branch St.
112
(City or town.)
St. :..
...... Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
.... Registered No.
39
....
....
10 NAME OF
FATHER
James Bailey
11 BIRTHPLACE
OF FATHER
(State or country)
Mass
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 minc, 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 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-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.
7 AGE (b) General nature of industry, business, or establishment in which employed (or employer). 9 BIRTHPLACE (State or country) 11 BIRTHPLACE OF FATHER (State or country) PARENTS 18 BIRTHPLACE OF MOTHER (State or country) (Informant). (Address) 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
113
.........
...........**
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Sarah le berglite
[If married or divorced woman or widow
give maiden name, also name of husband 1
@RESIDENCE
Southe bluelinefull
Registered No. .... 40
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Jemal White
+ COLOR OR RACE
"
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
5 SINGLE,
16 DATE OF DEATH
May 24th
1913~
....
(Month)
(Day)
(Year)
17 .
I HEREBY CERTIFY that I attended deceased from
May /6, 1915, to
May 24 1915
If LESS than
I day .........
....... hrs-
that I last saw her alive on
May/24 195
and that death occurred, on the date stated above, at 10 Pm
The CAUSE OF DEATH* was as follows :
Epidemia Inthengan
€
Bronchitis
-
(Duration)
yrs.
mos.
de.
Contributory.
(SECONDARY)
.. (Duration)
............. yrs.
.. mos.
ds.
(Signed)
Autumn 9. Icoloria
M.D.
May rs, 1915 (Address)
4 ....
* 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.
............. yTs.
mos.
Where was dlsease contracted, If not at place of death ?.
Former or usual residence ...... ....
19 PLACE OF BURIAL OR REMOVAL Eden
DATE OF BURIAL
May 26,
....
1915-
20 UNDERTAKER
ADDRESS
REGISTRAR Wambach
.......
......... Ward)
....
" DATE OF BIRTH
Dec 8,184.6
1
(Month)
(Day)
(Year)
5.8 5
.... mos.
14
ds.
-
......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
...........
Athird
10 NAME OF
FATHER
Serge Lenghtun
12 MAIDEN NAME
OF MOTHER
Elizabeth Semerla
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Filed. May 25, 1915 Edward S. Robbery
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Si Chelmsford No
-*
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, 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 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 cercbro-spinal meningitis") ; Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite),; Tuber- Will call for is
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.
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 no. Chelmsford (No. moins Mill St.
William
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.1 @RESIDENCE 247 While It. Low
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DWORCED
( Write the word)
16 DATE OF DEATH
Thay
(Month)
24 (Day)
191.5 (Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
accident
(Fall of scaffolding)
.. (Duration) .
.... yrs.
.. mos.
ds.
Contributory ...
Fracture-Dislocation of
.... myrs. .mos. ds.
(Signed)
DU. Meins
M.D
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
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 If Yough
DATE OF BURIAL May 26.1915
(Address)
247 White
18 May 25, 1915 Edward . Bobbing Filed_
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
6 DATE OF BIRTH Aunque 21 (Month) (Day)
7 AGE
If LESS than [ day, ......... hrs.
32 yrs. 11 mos.
3
ds.
or ......... min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work .. Bricklanger
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Lawell man Erical Vinterstore.
10 NAME OF FATHER Charles Saverney Na, 24, 1915 (Adress) 1611 Kernmack H
PARENTS
11 BIRTHPLACE OF FATHER (State or country) St. alban yf
12 MAIDEN NAME OF MOTHER Peulia Renaud
13 BIRTHPLACE OF MOTHER (State or country)
St alban 1-
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Hose anna Lucene
114
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Ward)
4
Registered No.
4)
1.882 (Year)
20 UNDERTAKER A chichambault him
ADDRESS 738 erruch
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 cxamples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who reccive 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 (rctircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, tlie DIS- EASE CAUSING DEATH (the primary affection with respect to tinc and causation), using always the same accepted term for the same discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
F
T
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, 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 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. 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 discase, as A death upon the strc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A pen found dead, etc.
7 AGE 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. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state -
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male White
6 SINGLE.
MARRIED2
WIDOWED
OR DIVORCE
(Write the word)
sovwed
A DATE OF BIRTH
Sehr 3 1823
(Month)
(Day)
. (Year)
If LESS than
1 day ......... hrs.
.............
..... yrs ....
8
.... mos. .
23
ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country}
Westford mars
(Duration)
.yrs.
mos. ds.
Contributory ....
(SECONDARY)
(Duration)
... yrs.
4 ..
.mos.
ds.
(Signed)
JE Varney
M.D.
Jug 26
1915
(Address)
H Schlafend
....
* 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. .........
.
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) __ Hun SengeW Swell
(Address) No thelmehrd.
18 le May 28, 1915 Edward Rafting REGISTRAR
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL Edenbeen May, 25 1915.
20 UNDERTAKER
ADDRESS
At Welbeck Market
(Month)
26
1915
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
May 1.
. 1915 to.
1918
....
1
.........
that I last saw ha alive on.
1915
.........
and that death occurred, on the date stated above, at 2pm.
The CAUSE OF DEATH* was as follows :
Cancer 9 lives
.
........
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE OF MOTHER (State or country)
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH North lehelmefind St. :
.115
.......... (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Phineas P Trow Budge
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
....
Registered No.
42
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
May
1
...
' COLOR OR RACE
92
MARGIN RESERVED FOR BINDING
1 PLACE OF DEATH
.......... Ward)
........
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oceu- 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 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.
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