USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 33
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... mos.
ds.
............
Where was disease contracted, If not at place of death ?...
Former or usual residence .. .....
19 PLACE OF BURIAL OR REMOVAL DATE OF BURIAL St Patricks Cen July 17
20 UNDERTAKER AR O Connell.
ADDRESS
1915-
16 Filed _.. July 16 , 1915 Llevard . Robbers
REGISTRAR
128
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE Male White 5 SINGLE, MARRIED WIDOWED OR DIVORCED (Write the word) * DATE OF BIRTH (Month) (Day) 7 AGE & OCCUPATION (a) Trede, profession, or particular kind of work (b) General nature of Industry, business, or establishment in which employed (or employer) ... 9 BIRTHPLACE (State or country) Jewell 11 BIRTHPLACE OF FATHER (State or country) PARENTS 18 BIRTHPLACE OF MOTHER (State or country) Jewell. 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 .. ...... 11 mos. 8 ds.
1
(Year)
If LESS than
I day ......... hrs.
= ........ min. ?
......
10 NAME OF‹ FATHER Daniel Exam
12 MAIDEN NAME
OF MOTHER
Grace allen
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Daniel D'Have
(Informant)
(Address) 53 Wmel M
. (City or town.)
191.
....
.......
......
.................
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulncss 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 linc 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," "Dcaler," 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, ctc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fevcr (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-
culosi's 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," 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No , St. John's Hospitals
Sti
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
freeph Janey
n. Chelmsford Mass
Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
13
(Month)
(Day)
1915
(Year)
I HEREBY CERTIFY that I attended deceased from
July 14, 1915, to July 15
1937
.
that I last saw him alive on
115
1915
and that death occurred, on the date stated above,
910
a.m.
The CAUSE OF DEATH* wasf as follows :
typhoid
Fever
.......
.. (Duration)
... yrs.
.mos .. ds.
Contributory ..
(SECONDARY)
(Duration} yrs.
.mos.
ds.
((Signedà
L'homast 6 Friend
M.D. Sily 16, 19/ 5 (Address) St. John's Hoep.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place of death .. yrs. .. mos.
In the
.. ds.
State ............ yrs.
mos ..
ds ....
Where was disease contracted, If not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL St. Patrick Cemetery July 17, 1915
20 UNDERTAKER
J. F.G' Donnell + Long M.
PRESS arket St.
1PLACE OF DEATH
Lowell Mass,
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
male White
1 5 SINGLE,
MARRIED
Single
WIDOWED,
OR DIVORCED
( Write the word) Our
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
16.
O.yrs.
-mos.
.ds.
or ......... min. ?
8 OCCUPATION
Operative
(a) Trade, profession, or
particular kind of work ...
(b) General nature of industry,
Woolen Mill
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
M. Chelmsford mass
10 NAME OF
FATHER
Patrick Jansy
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Catherine M.Cabe
PARENTS
18 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
and
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Father
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.
(Address)
M. Chelmsford Mars
16
Filed ..
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
....
Plus REGISTRAR
127
Lowell ...
...
5-6
29576
6
....
.........
If LESS than
I 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, 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, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housc- kcepers 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 (retircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- LASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fevcr (the only definite synonym is "Epidemic 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, 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) affeetion 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," ete.), "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.
-
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 Ho. Chefesford (No.
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Stilllow (DE Cartunk)
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
No. Chelmsford
Registered No.
5/
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
.
1910
1
(Month)
(Day)
(Year)
6 DATE OF BIRTH
28
1915
(Day)
(Year)
7 AGE
If LESS than
1 day,
....... hrs.
mos. ds.
or ........ min. ?
& 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).
"no. Chelmsford
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
North, Released Mass
12 MAIDEN NAME
OF MOTHER
Ada Swanwick
13 BIRTHPLACE
OF MOTHER
(State or country)
England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
alfud De Cartunik
(Address)
OH, Chekuo ford
15
Filed. July 28, 1915 Edward J. Rol fing
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
191.
...... , to
why 28
that [ last saw h
..... alive on.
191.
........
and that death occurred, on the date stated above, at 6-30pm.
The CAUSE OF DEATH* was as follows :
Premature buch
(Duration)
.......
.... yrs.
.mos. ds.
Contributory.
(SECONDARY)
..... (Duration)
yrs.
mos.
.......
.ds.
(Signed)
JEVarney
M.D.
1915 (Address).
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
1ª 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 ..
19 PLACE OF BURIAL OR REMOVAL River Side Secret
DATE OF BURIAL
0, Le 2/ 1915
20 UNDERTAKER
2.5 WEEKS
ADDRESS
2.0 Chelmsford
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
3 SEX male
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
(Month)
.. yrs.
1
138
(City or town.)
....
10 NAME OF
FATHER
Alfred DeCarteret
STANDARD CERTIFICATE OF DEATH.
-
Statement of occupation. - Precise statement of occupa- tion 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 occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE 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 provisions of chapter 24 of the Revised Laws deaths under the following 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
131 So Chelafar (City or town.)' [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. :
Ward)
58 Registered No. 564
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
30
1910$
(Year)
(Month)
(Day)
17
I HEREBY CERTIFY that I attended deceased from
July 22, 19/5, to
191
......
........
that I last saw han alive on
July 202, 195
and that death occurred, on the date stated above, at ....
.........
m.
The CAUSE OF DEATH* was as follows :
Ajocardial Degeneration.
.(Duration)
........
.. yrs.
mos.
ds.
Contributory
(SECONDARY)
mos.
(Duration) ...
· ................ ds.
(Signed)
Auchan 4, o cobora
M.D.
, 1915 (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).
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 .......
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL ang 2, 1915
20 UNDERTAKER
Joseph albert
/ADDRESS
17) arken th
Lowell
1 PLACE OF DEATH
So. Chelmsford
.(No
2 FULL NAME
Victor Larase
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
1 5 SINGLE,
male White
WIDOWED.
OR DIVORCED
(Write the word)
* DATE OF BIRTH
...
(Month)
(Day)
7 AGE
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
at Home.
(b) General nature of industry,
business, or establishment In
which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Canada.
10 NAME OF
FATHER
Victor Larose.
11 BIRTHPLACE
OF FATHER
(State or country)
Canada.
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
Camada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
mix. I.G. Houle.
important. See instructions on back of certificate.
(Address)
So Chelmsford.
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 ...
80 yrs. 7 mos. 10
ds.
or ......... min. ?
1
(Year)
If LESS than
1 day ........ hrs.
12 MAIDEN NAME
OF MOTHER
Javette Cabana
Filed. any, 2, 1915 Edward J. Roffing
0
REGISTRAR ....
....
[If married or divorced woman or widow
give maiden name, also name of husband.1
@RESIDENCE
Lo. chelmsford. mars.
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) ; Mcasles; 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," "Scnile," 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 strect, or one supposed to be due to Alcoholism, ctc.
4. Deaths under circumstances unknown, as A person found dead, etc.
-
-
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
.
1 PLACE OF DEATH
Chelmsford
(No.
Locast Road
CharlesW. By and
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Long Road
Registered No.
59
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED
WIDOWED,
(Write Webdelsweet
6 DATE OF BIRTH
Vune
19
1832
(Month)
(Day)
(Year)
7 AGE
83
.. yrs.
mos.
mos. 12 ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Detund
(b) General nature of industry, business, or establishment in which employed (or employer) ..
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