USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 30
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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 "Epidemie 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," "Hemorrhage," "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.
COMMONWEALTH OF MASSACHUSETTS
116
RETURN OF A DEATH-1915.
CITY OF BOSTON.
FULL NAME
Place of Death ) and Residence
Boston
JUNE 8
17
10
4
1915.
Age
years
months days.
43
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
SIN.
Maiden Name
Husband's Name
Birthplace
NEW BEDFORD
Name of Father
FRANCIS MARTIN
Birthplace of Father
NEW BEDFORD
Maiden Name MARY SMITH
of Mother
Birthplace PROVINCETOWN
of Mother
SPINNER ( WOOLEN MILL)
Occupation
Informant
Place of Burial or removal
LOWELL(ST PATRICKS)
Undertaker
G. W. HEALEY LOWELL
Usual Residence NO. CHELMSFORD
Filed
JUNE 11 1915.
A true copy. Attest :
Enmylenew
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 :
R AR'S
UT PATRIBAS, SI'
Primary: ( Duration)
TEFICE
( SUICIDAL -DURING TEMPORARY
BOSTONIA
CONDITA AL
ATA A.1822.
INSANITY)
ISREGIMI BOSTO
N. MASS
Contributory : (Duration)
T. LEARY MED.EX .
(Signed)
M.D.
JUNE 9 1915
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Registrar.
O
MARY E. MARTIN
Registered No.
5712
POLICE AMBULANCE DIV.5
Date of Death
CITY REG
PISTOL SHOT WOUND OF CHEST
SLEVLLA32
٥
சங்குகு
D
2
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH lehelmand .(No.
...
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Eliga A Milliken
2 FULL NAME [If married or divor or widow Perham Sachuan Milliken
give maiden name, also name of husband.]
@RESIDENCE
le pehmefra
Registered No. 44
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Female
4 COLOR OR RACE :
white
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORGGO/
(Write the word)
6 DATE OF BIRTH
Sekx 20-184.3
....
(Month)
(Day)
1
(Year)
If LESS than
I day ......... hrs.
8 OCCUPATION
(a) Trade, profession, or Vivavoce
particular kind of work
(b) General nature of Industry, business, or establishment In which employed (or employer) ...
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
James Perham
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE
OF MOTHER
(State or country)
Freeman Me
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
....
19 PLACE OF BURIAL OR REMOVAL Edern
DATE OF BURIAL
true 18.
191 51
(Address)
Chebefria
16 Filed June e 18, 1915 Edward &. Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
17
June 3
1915
June 15. 1915.
to
that I last saw her alive on.
June 15 1915
and that death occurred, on the date stated above, at 7:10 Pm
The CAUSE OF DEATH* was as follows :
Right farmiplegia
.. (Duration)
.yrs.
.mos. .
13 de.
Contributory.
Myocarditis- Endocarditis and
.....
(Duration).
2/03
mos.
....
ds.
(Signed)
Arthur G. Scolonial
M.D.
June/6, 1915 (Address)
Chilunsford, Mads.
.......
(* 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. ..........
20 UNDERTAKER
AR Sed Nembech
ADDRESS
Machet
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
7 AGE PARENTS (Informant). CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ....
61
.yrs.
/
8
mos.
20
ds.
or ......... min. ?
15 DATE OF DEATH
1
19140
(Month)
(Day)
(Year)
St. ;.............. Ward)
9
yrs.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precisc statement of oecu- 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 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 Housc- 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 NEATH, state occupation at beginning of illness. If retired from business, that faet 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- DASE CAUSING DEATH (the primary affeetion 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 "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indcfinite); Tuber-
culosis of lungs, meninges, peritonaeum, ctc., 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,". "Shoek," "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, ete.
4. Deaths under circumstances unknown, as A person found dead, ete.
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 Owell Mars (No Lowell Con 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
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford may.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
' COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) >
Lind
6 DATE OF BIRTH
Jun
(Month)
15
19/15
(Day)
(Year)
7 AGE
If LESS than
1 day. _. hrs.
4
.. yrs. -mos. ds.
....... 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)
Lowell Mass
PARENTS
12 MAIDEN NAME
OF MOTHER
Mary E. Davidson
13 BIRTHPLACE
OF MOTHER
(State or country)
maine
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Father.
(Address)
Chelmilord Class).
16 Filed June 2 5 9/ 5/2/2
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
June
19
19137
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
,
191.
to.
191-
that I last saw him alive on June 1
195
and that death occurred, on the date stated above, at ................... m.
The CAUSE OF DEATH* was as follows :
Premature Birth
... (Duration)
....... yrs.
.... mos.
ds.
Contributory ...
Mother Suffered Eclampsia
(SECONDARY)
mos. .(Duration) .yrs. ds.
(Signed)
I & Cassidy
M.D.
June 21, 19/05 Adress) 504 Such Blog
If death followed injury or violence the certificate of death must be made lout 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 ..
1 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Ting ridge
Chelmsford
Cemetery
Maso June 22 1915
1 ...
20 UNDERTAKER
"Blake
ADDRESS
33 Prescottst
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
118
Lowell ....
William Brown
Registered No.
45
10 NAME OF
FATHER
William Brown
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland
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 Housc- 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 "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fcvcr (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonacum, 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- acmia" (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- posurc, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or onc 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 Chelmsford
.......................
(No
Billerica Road
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Everett Undama Toper
[If married or divorced woman or widow give maiden n @RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX7
M
14 COLOR OR RACE
5 SINGLE,
MARRIED.
WIDOWED.
OR DIVORCED
(Writethe way gle
16 DATE OF DEATH
June
201
1915
....
(Month)
(Day)
.,
(Year)
$ DATE OF BIRTH
Lune
NO 1915
(Year)
(Month)
(Day)
PAGE
0
.yrs.
mos.
1
ds.
or ......... min. ?
S 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)
Clickusted, Mass
10 NAME OF
FATHER
William F. Doper
11 BIRTHPLACE OF FATHER (State or country)
Lowell mass
12 MAIDEN NAME
OF MOTHER
Pauline Adams
18 BIRTHPLACE
OF MOTHER
(State or country)
Lowell, Mais
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mes. Koper
(Address)
16 Filed Jame 2/1, 1915 Edward , Robin
REGISTRAR
17
....
I HEREBY CERTIFY that I attended deceased from
June 10 95 to
Jmu 20
1915
.....
If LESS than
I day ....
.... hrs.
that I last saw him alive on.
Jam 20
1915
and that death occurred, on the date stated above, at 90-
The CAUSE OF DEATH* was as follows : Enteritis
(Duration)
............. yrs.
.mos.
ds.
Contributory ... ....... (SECONDARY)
(Signed)
Amasa toward
... (Duration) .
....
yrs.
.mos.
......
M.D.
Que 21, 1915 (Address). 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).
In the
At place of death ... yrs.
.. mos.
ds.
State ....
....... yrs. ............ mos.
.........
.ds .............
Where was disease contracted, If not at place of death ?. ..... usual residence .. Former or
12 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
toretactics De heelves ford. May June 21.
1915
ADDRESS
20 UNDERTAKER
Walter Parliam Chelinesford
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
chelmsford
Registered No. 4.6
...
:
PARENTS
10
ds.
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 indefinitc) ; 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Scnile," ctc.), "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 8 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
East Chietinsford
(No
Centre St
St. :
......... ........................ .. Ward)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
? FULL NAME ..
Lucy a. Houver
Lucian H. However
East Chelmsford Wass
Registered No. 1217
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
Female White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
16 DATE OF DEATH
hul 21
1
(Month)
........
(Day)
..
1915
(Year)
"DATE OF BIRTH
July
ed
(Month)
(Day)
18JA
(Year)
If LESS than 1 day ......... hrs.
44 myr. 11 mos. 19 ds.
or ......... min. ? -
(a) Trade, profession, or
particular kind of work
......
House wife
(b) General nature of Industry, business, or establishment In which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Virginia
10 NAME OF
FATHER
Lewis Marsteller
11 BIRTHPLACE
OF FATHER
(State or country)
Indianana
12 MAIDEN NAME
OF MOTHER
Mildred Brawner
18 BIRTHPLACE
OF MOTHER
(State or country)
Virginia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Luciantt, Hanver
(Informant).
) ----
(Address)
Cast Clubsford
16 Filed June 23, 1915 Edward S. Robbins
REGISTRAR
about 1,
...
.(Duration) ......
.yrs.
.. mos.
ds.
Contributory
(SECONDARY)
(Duration)
I .ds.
yes.mos.
(Signed)
Attund, seabonar
...
M.D.
Qual 22 05
Clubinsfail Mars,
...............
(Address)
* If death followed injury or violence the certificate of death must'be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS ..
At place
of death
.. yrs.
mos.
ds.
State ..
In the
... yrs.
... mos.
......
ds .............
Where was disease contracted, If not at place of death ? ....
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Edson Cemetery
DATE OF BURIAL
June2 31915
20 UNDERTAKER
Seoul. Eastman 363 Bridge St.
120 East Chelusfor (City or town.)
............
47
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
-
I HEREBY CERTIFY that! attended deceased from May 5, 1915 to June 20 1995 that I last/saw her alive on. Arma 20, 195. and that death occurred, on the date stated above, at 1/09 m. The CAUSE OF DEATH* was as follows : Intercalar Peritonitis
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