USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 32
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18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
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 St. freethe Chelmsford Incon
DATE OF BURIAL
July 7
1915-
.........
20 UNDERTAKER
I. S. Holton
ADDRESS
Her. Chelmsford
.
0
4 COLOR OR RACE
Dbhit
5 SINGLE,
MARRIED,
Single
WIDOWED
OR DIVORCED
(Write the word)
124 Chelmsford (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
...
In the
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.
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
Ofelvisford (No. Activ
.,
William Henry Jefts
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
lebelinsfund
100
Registered No. 52
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
Male White
4 COLOR ØR RACE
5 SINGLE,
MARRIED,
WIDOWED,
Harried
(Write the ward
· DATE OF BIRTH
Apr. 19-1829
(Month)
(Day)
(Year)
If LESS than
! day ......... hrs.
87 ...... yrs.
2
22
„ds.
or ......... min. ?
(a) Trade, profession, or
particular kind of work ..
Retired
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
From Woulder
9 BIRTHPLACE
(State or country)
Bellenca Nais
11 BIRTHPLACE
OF FATHER
(State or country)
Billerica, Mars
12 MAIDEN NAME
OF MOTHER
Lucretia Snow
18 BIRTHPLACE
OF MOTHER
(State or country)
Concord. mas
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. W. H Jefts-
(Address)
Chelmsford
18
Filed ... July 12, 1915 Edward & Robbins
......
.....
REGISTRAR
17
I HEREBY CERTIFY that l)attended deceased from
191
....... ,
to 1
we 1495
that I last saw h.AMalive on.
June 14.
.... ,
A
. 1915 2 .. , and that death occurred, on the date stated above, at .... ............. ... m.
1
The CAUSE OF DEATH* was as follows :
Myocardial Digeneration
-
Senility
(Duration)
yrs.
.. mos.
ds.
Contributory
(SECONDARY)
(Sighed)
Arthur J Scoloria
....
M.D.
617/2, 191) (Address).
Chilin food, 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, CR 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 Lowell Cern .
DATE OF BURIAL
July 13.
.,
1915
.............
UNDERTAKER
Waller Lechan
ADDRESS
Chechens feed.
.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
? AGE
8 OCCUPATION
.
10 NAME OF
FATHER
PARENTS
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
...........
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
(Month)
(Day)
11
191
(Year)
.....
.... ,
125 Chelcustard
........
St. :
.........
Ward)
(Cityor town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
.. mos.
... ds.
..... (Duration)
... yrs.
......
5
1
mos. .
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 septicemia," "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
1 PLACE OF DEATH Lowell Mass,(No St. John's Hospital Sta: Ward)
126
Lowell .......
(City or town.) Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
Nellie Donahoe.
nellie O'neill - James Q Donahop.
6. Chelmsford Mass
Registered No. 3
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
19
(Month)
(Day)
1919
(Year)
I HEREBY CERTIFY that I attended deceased from
(Year)
May 24
1915 to July 11
1912
that I last saw her alive on.
1915
-
and that death occurred, on the date stated above, at 1 40 m.
The CAUSE
OF DEATH* was, as follows :
Cerebral Hemorrhage
(Duration) .
.... moș.
.... ds.
. ....
.....
Contributory.
Chroni Interstitial Nephrit.
(SECONDARY)
(Duration) yr$ ( mos.
ds.
Fred Murphy
M.D.
(Signed)
July 12, 1915
(Address) ......
219 Central
......
+ If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
ds.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS),
At place
In the
of death
yrs.
... mos. ...
ds.
State
.......... yrs.
.mos.
Where was disease contracted, if not at place of death ?. Former or
usual residence ...
E Chelmsford mars
19 PLACE OF BURIAL OR REMOVAL DATE OF BURIAL St. Patrick Cemetery July 13
1910.
20 UNDERTAKER J. F. Rogers
ADDRESS 44 32 Gorham St
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
3 SEX
14 COLOR OR RACE
témale White
& DATE OF BIRTH
.....
(Month)
(Day)
7 AGE
60
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
none
(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)
freland
PARENTS
13 BIRTHPLACE
bland
OF MOTHER
(State or conntry)
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
...
... yra.
mos.
ds.
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED !
( Write the word) Widower
1
If LESS than
I day .......... hrs.
or ..........
....... min. ?
Erton Mass
10 NAME OF
FATHER
Patrick @ Meill
12 MAIDEN NAME
OF MOTHER
Mary Gallery
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Miss m. O'neill
(Address)
5784
Gorham HH!
16 Filed
REGISTRAR
17
PERSONAL AND STATISTICAL PARTICULARS
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 necded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Groccry; (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 arc 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 Scrvant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (rctired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, ctc., of. ....... .(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; 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 (sccondary), 10 ds. Never report merc symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mercly 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 discase 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, ctc.
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.
2 FULL NAME 3 SEX 7. ......... PAGE 8 OCCUPATION (a) Trade, profession, or particular kind of work PARENTS important. See instructions on back of certificate. (Address) 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 0
The Commonwealth of Massachusetts
Cheliefert.
STANDARD CERTIFICATE OF DEATH
1 PERCE OF DEATH
(No
Turnpike Odst.
e
Cemily May trink
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
1 5 SINGLE
MARRIED,
WIDOW ED.
OR DIVORCED
(Wie the worm ale
· DATE OF BIRTH .
(Month)
(Day)
1914 (Year)
If LESS than
1 day ......... hrs.
yrs.
8
mos.
21
ds.
Or ......... min. ?
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Cefichusford
10 NAME OF
FATHER
Ahah W. Frink
11 BIRTHPLACE
OF FATHER
(State or country)
untry Deering, Me
12 MAIDEN NAME
OF MOTHER
Echef M. Bonner
13 BIRTHPLACE
OF MOTHER
(State or country)Pean
m. Mais
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
mix, trick
1 Filed .. July 15, 195 Edward Mobbing ....
REGISTRAR
17
I HEREBY CERTIFY that
attended deceased from
Jama 20 1915
..... ,
, to
July 14, 1915
that I last saw h Le. alive on.
July 1 4, 1915.
and that death occurred, on the date stated above, at.
... m.
The CAUSE OF DEATH* was as follows :
Enterocolitió
Secondary Mengetes
-
2 WEEKS .
.mos. ..... „ds.
Contributory
(SECONDARY)
.(Duration), .............. yrs.
.mos.
ds.
(Şigned)
Autumn / Scottona,
M.D.
July 17, 1915 (Address).
......
Chilensford, Inass.
* 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
DATE OF BURIAL
line Didge July 16.
1915
.......
20 UNDERTAKER ! Walter Perland Schelmsford.
Ward)
(City or town.) fif death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
54
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
14
1910
.....
(Day)
(Year)
(Duration)
... yrs.
...............
4 COLOR OR RACE
w
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 scpticaemia," "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.
i
-
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 East Chelmsford .................. (No ....... Frederick D'Hara
St. ;........................ Ward)
[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
53 Ponad At Lawell
....
Registered No.
55
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
15
(Month)
(Day)
........... (Year)
17
I HEREBY CERTIFY that I attended deceased from July 12, 1915, to. .......
1915
1
that I last saw h alive on
191.
m. ........ .......... and that death occurred, on the date stated above, at 9-0 The CAUSE OF DEATH* was as follows : Inforcular Minugata
(Duration)
.. yrs.
mos.
10 da.
Contributory ..
(SECONDARY)
.(Duration)
.yrs.
.mos.
... ds.
(Signed)
Marthun Makamsy
M.D.
July 16 1915 (Address) 169 Menumache St
* 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.
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