USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 31
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Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56
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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, Architeet, 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 homc, 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, peritonacum, etc., Careinoma, Sar- eoma, etc., of ... . (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronie 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," "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 diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical opcration 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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
IBLACE OF DEATH
(No.
Son Chelenfindst.
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Lunge
2 FULL NAME [If married or divorced woman or widow give maiden name, also nameof husband ] @RESIDENCE Cheles fonds
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
M
4 COLOR OR RACE
5 SINGLE
MARRIED,
Widowed
OR DIVORCIO
(Write the word)
16 DATE OF DEATH
June
24
(Month)
(Day)
1910
(Year)
" DATE OF BIRTH
21
(Month)
(Day)
(Year)
AGE
51
.
.yrs ..
10
mos.
3
.ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
farmer
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
Chronic nexturitito
... (Duration).
............... yrs ..
. ...
......
.mos. ds.
Contributory.
(SECONDARY)
(Duration)
mos ..
............. yrs. ................ mos.
...........
.ds.
1
Signed)
Anton 4, colonia
.... ,
M.D.
(Address).
Chilisfond 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
.. yTS,
...
.mos.
ds.
Where was disease contracted, If not at place of death ?.. Former or usual residence .. ........
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Rhoda Penny
nin
(Address)
So Cheliford
15
Filed June 26, 1915 Edmond S. Gallina
¿__ REGISTRAR
.,
191
....... ,
to
......
1
that I last saw how alive on.
Anne 2 ts, 1915,
and that death occurred, on the date stated above, at ....
m.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
Stone ham
10 NAME OF
FATHER
Robert Pennin
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Winden UR
12 MAIDEN NAME
OF MOTHER
Rhoda Chace
13 BIRTHPLACE
OF MOTHER
(State or country)
Canterbury A.
......
19 PLACE OF BURIAL OR REMOVAL Eden tem. howell.
DATE OF BURIAL
June 27 95
20 UNDERTAKER
Waller Veckan
ADDRESS
Chechuefond.
important. See instructions on back of certificate.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
12/
. :
Registered No.
48
I HEREBY CERTIFY that I attended deceased from
If LESS than
1 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, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, ctc. 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 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 (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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
...........; Church
St. :
Ward)
felly Afand 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Which It both Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
1 PLACE OF DEATH
And (No
3 SEX
{ COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Female
· DATE OF BIRTH
phar
(Month)
(Day)
7 AGE
8 OCCUPATION
Obecalis
(a) Trade, profession, or
particular kind of work
(b) General nature of industry
business, or establishment in
which employed (or employer) ...
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
important. See instructions on back of certificate.
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.
... mos.
.ds.
Vingle
1877 (Year)
If LESS than 1 day ........ hrs.
........ min. ?
Sollen mil
9 BIRTHPLACE
(State or country)
Forth Chelesford
10 NAME OF
FATHER
Vitawhen Shared
pher
11 BIRTHPLACE
OF FATHER
(State or country)
Queland
12 MAIDEN NAME
OF MOTHER
Ellen Donnelley
Cheland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant
1) Doretta V Said, Vister
(Address) Church th Chemin Ford
Filed. July 2, 1915 Edward &. Robbing .............. REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
april 1st, 1915,
to
Muz 29, 19115.
....
that I last saw has alive on.
Ihme 28, 19/5.
and that death occurred, on the date stated above, at 7.4m.
The CAUSE OF DEATH* was as follows :
Pulmonary tuberculosis
.. (Duration)
..... yrs.
mos.
ds.
Contributory
Methatis
....
(SECONDARY)
(Duration) .
„yrs.
................ mos.
. ..........
... ds.
(Signed)
............
M.D.
ne 29
1915
Address) No. Chelmsford
If death followed injury or violence the certificate of death out by the Medical Examiner.
must be made
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
In the
At place
ds ..
of death
yrs.
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
DATE OF BURIAL
F. Fattura Cemetry fecha 2 00
.....
20 UNDERTAKER
ADDRESS
22
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.}
....
Registered No.
49
1915
(Month)
29
(Day)
......... (Year)
.......
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 fircman, 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," "Forcman," "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 onc 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
Chelmsford
(No.
Town Harman
St. ;..................
Ward)
(City er town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
50
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
7
1915.
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that attended deceased from
*
191
....
ton
July 7
1915
that I last saw home alive on ..
1915
....... ,
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Mycardial Degeneration
Patauch al
Kanndiee
-
+
.(Duration)
... yrs.
............... mos.
ds.
Contributory ...
(SECONDARY)
(Duration)
......... mos.
.............
............ yrs.
... ds.
(Signed)
Autre Y, coboria
M.D.
July 8, 1915 (Adres).
Chelunsford, 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 Edson Comme Lowell
DATE OF BURIAL
July 9
..................
1915
.......
15 July 81, 19:5Edward J. Robbing Filed
0
REGISTRAR
20 UNDERTAKER
Walter Perham
ADDRESS Chelmsford
......
.... ,
.:
.,
1
..........
....
....................
2 FULL NAME
Jacob Hauver
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
white
Male
! 5 SINGLE,
MARRIED,
Widowed
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
-
1832,
....
(Year)
(Month)
(Day)
FAGE
If LESS than
1 day ......... hrs.
83
yrs.
mos.
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)
Canada
10 NAME OF
FATHER
Houver
11 BIRTHPLACE
OF FATHER
(State or country)
Canada
12 MAIDEN NAME
OF MOTHER
PARENTS
18 BIRTHPLACE
OF MOTHER
Canada
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
arlin To. Horstin
(Address) Laurane
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
....
123
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, Houscwork, 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 male PAGE PARENTS important. See instructions on back of certificate. N. B. - Every Item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ............
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Stret Chelmsford,
(No
St. ;...................
Ward)
miner
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Trat Chelmsford
Registered No. 51
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July 7
........
(Monthy
(Day)
1915
....
(Year)
· DATE OF BIRTH July (Month)
7
(Day)
1915
(Year)
If LESS than
! day ......... hrs.
mos.
d&.
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 hast Chelmsford
10 NAME OF
FATHER
arthur . Miner
11 BIRTHPLACE
OF FATHER
(State or country) Cell mass
12 MAIDEN NAME
OF MOTHER
alice a. magnant
13 BIRTHPLACE OF MOTHER (State or country Williamantic Com
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
arthurP miner
(Address) Chelaland mass
16 July 7, 1915 Edward J. Robbing Filed
REGISTRAR
....
17 I HEREBY CERTIFY that I attended deceased from
191.
..... ,
July 7
., 1913~
to
that I last saw her alive on
.... .
1915
and that death occurred, on the date stated above, at /4. m.
The CAUSE OF DEATH* was as follows :
Fremative Berth
...
livro 15 a 20 minutes
.(Duration) .
... yrs.
mos. ds.
Contributory ..
(SECONDARY)
........... .......
1
(Duration)
.yrs.
.. mos.
ds.
(Signed)
t. G.Varney
M.D. July 7, 1995 (Address) No. Chelmsford
....
* If death followed injury or violence the certificate of death must be made ont by the Medical Examiner.
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