USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 38
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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.
1
-
1915- 60-
1866-
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 120 Chelmotor (No. 15 Gau
St. ;.. ................. Ward)
Beverly Mr. Marshall.
......
......... ......
75
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
Married.
18.65. (Year)
If LESS than ¡ day ......... hrs.
(a) Trade, profession, or
particular kind of work
Elevator Man.
9 BIRTHPLACE
(State or country)
New Brunswick.
| 10 NAME OF
FATHER
Marshall.
11 BIRTHPLACE
OF FATHER
(State or country)
New Brunswick.
12 MAIDEN NAME
OF MOTHER
Isabelle Marshall.
13 BIRTHPLACE
OF MOTHER
New Brunswick.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
More. Martha S. Marshall
(Address)
No. 6 helmafords
16 Nov. 4. 1915 Oderand Spotting Filed_ ..... ......
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Nov.
(Month)
(Day)
1915
(Year)
17
I HEREBY CERTIFY that I attended deceased from
15, 1915, to
Nov , 1915
that I last saw halive on.
nov
1, 1915.
and that death occurred, on the date stated above, at 2 45Pm
The CAUSE OF DEATH* was as follows :
Heart
mit Requisitoto
(Duration) .
2
w ... yrs.
mos. ds.
Contributory ...
Caroline asthma
...........
(SECONDARY)
9
.(Duration) yrs.
.mos. ds.
farmer total
M.D.
(Signed)
........
......
(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
.mos.
In the
....
ds ..
.........
of death.
... yrs.
...... mos.
ds.
State
.yrs.
. .........
Where was disease contracted,
If not at place of death ?. ..... Former or usual residence. ................
19 PLACE OF BURIAL OR REMOVAL
.............
DATE OF BURIAL
Pepperell Mare. Nov, 4, 1915
20 UNDERTAKER
grof Healey.
ADDRESS
79 Branch &X.
148 No. Chelmsford. (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
....
2FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
15 gay 8 8
8 SEX
Male.
4 COLOR OR RACE
1 5 SINGLE,
MARRIED
WIDOWED)
OR DIVORCED
(-Write the word)
White
· DATE OF BIRTH
Many
-.
(MonsE)
TAGE
50
8 OCCUPATION
Mill.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
PARENTS
(State or country)
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
....
.... yrs.
6
.. mos.
ds.
...
1.
(Day)
or ........ min. ?
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 nceded. 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 homc. 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," unqualificd, is indefinite) ; Tubcı .
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," "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 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 7. TAGE PARENTS important. See instructions on back of certificate. 15 N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ....
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford
No ToFarm
St. :
...............
...
Ward)
(City dy town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Sarale Harney Hamis
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.1
@RESIDENCE
Clulmus 7
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
1 5 SINGLE,
MADRID,
WoweD,
Single
(Write the word)
" DATE OF BIRTH
...
(Month)
Way)
18:42
(Year)
If LESS than
¡ day, ........ hrs.
73
8
mos. 17 ds.
„mos. ....
.... yrs.
or ........ min. ?
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)
Calrt Ut.
10 NAME OF
FATHER
Samer M. Harris
11 BIRTHPLACE
OF FATHER
(State or country)
Danville Ut
12 MAIDEN NAME
OF MOTHER
annette M. Haseltine
18 BIRTHPLACE
OF MOTHER
Danville VA
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Www. Hardy
(Address)
Eineland Mark
Filed.
7-202.3 1915 Edward ), Rafting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17 I HEREBY CERTIFY that I attended deceased from
.......
191.
.........
that I last saw her alive on.
nov. 2
., 1915
...
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was, as follows : "
Chronic nephreter
-
.....
mos.
ds.
.(Duration) ..
.. yrs.
.................... .......................
............
Contributory ...
(SECONDARY)
......
Duration
.... yrs.
.mos.
ds.
(Signed)
Zur. 4, 1915 (Address).
Chilineford, Mas
* 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
Danville Center VA
DATE OF BURIAL
Mar. 4.
19115
....... ,
20 UNDERTAKER
Waller Perham
ADDRESS
Chelmsford.
149
-..
...
76
4 COLOR OR RACE
2.
17
(Month)
(Day)
3
1915
(Year)
to
nov. 2 1915
M.D.[
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 nceded. 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 usc 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 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
PLACE OF DEATH No Mehmetna (No. Nufieles 10
St. :
Ward)
2 FULL NAME
Maria Echnative
[If married or divorced woman or widow, give maiden name, also name of husband Ceembell Milian Rentedminstens @RESIDENCE
Registered No.
77
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
Nav 8 1829
(Month)
(Day)
1
(Year)
7 AGE
86
..... yrs. ....... ..... mos. .ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Attnul
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Sortland
1
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
Clancy
Dock
13 BIRTHPLACE
OF MOTHER
untry Sattand
14 THE ABOVE IS TRUE TO,THE BEST OF MY KNOWLEDGE
(Informant)uz Alem ando Mayo / Lag
(Address) Dubbelelang
16
Filed ... 201. 10, 1915 Gamand & Robbins ...... ....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
8:
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Sf1-30
,
1918, to.
.......
that I last saw him alive on
nor 7
1915~
and that death occurred, on the date stated above, at 9 a.m.
The CAUSE OF DEATH* was as follows :
Senility
graduel declino day & age
and antino delevis
(Duration).
................ yrs.
ds.
....
Contributory.
(SECONDARY)
.... (Duration) ............. yrs. ................ mos. ............
ds.
(Signed)
M.D.
.. 191 (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
In the
of death
.... yrs.
.....
.mos.
ds.
State
.. yrs.
.....
.mos. . ............ OS ............. Where was disease contracted, If not at place of death ?. ........... ....... Former or usual residence. .................................
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Mathelaufe w 11, 194.
20/UNDERTAKER
ADDRESS
150
(City or town.)
fif death occurred in a hospital or institution, give its NAME instead of street and number.]
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
10 NAME OF
FATHER
le hu lecambell
If LESS than
[ day
... hrs.
1910
.....
-
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.
1
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
1 PLACE OF DEATH 2 FULL NAME 3 SEX 71. YAGE 8 OCCUPATION (a) Trade, profession, or particular kind of work (b) General nature of industry, business, or establishment in which employed (or employer). 11 BIRTHPLACE OF FATHER (State or country) PARENTS 13 BIRTHPLACE OF MOTHER (State or country) (Informant). 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 ............. ....... yrs.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
.(No
Tutman Que
St. :
Ward)
(City of town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Larale am Holt
[If married or divorced woman or widow. give maiden name, also name of husband.] @RESIDENCE Chelinsford
PERSONAL AND STATISTICAL PARTICULARS
| + COLOR OR RACE
5 SINGLE
MARRIE
WIDOWER
Married
OR DIVORE
(Write the wordy
26 855
(Month)
(Day)
(Year)
If LESS than 1 day ......... hrs.
mos.
.........
.„ds.
or ........ min. ?
at home
9 BIRTHPLACE
(State or country)
England
10 NAME OF
FATHER
Samuel Howarth
England
12 MAIDEN NAME
OF MOTHER
Unknown
England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Filed.
.......
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
nov,
17
(Month)
(Day)
1915. (Year)
17
I HEREBY CERTIFY that I attended deceased from
Oct 2 3,
191.
to nov
1915
.........
that I last saw h
alive on
19|
.m. ...... and that death occurred, on the date stated above, at .... ............
The CAUSE OF DEATH* was as follows :
Pulmonary Hammarhoge
.....
(Duration)
... yrs.
mos.
ds.
Contributory ...
(SECONDARY)
(Signed)
Arthur C. 8).
............... yrs. ..........
.... mos. ............
ds.
colonial
M.D.
200.20 1915 (Address) Chilvegfood, Maso.
* 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
Edrow Sem. Rowell Nov. 20
191.
15 nov.20 1015 Edward & Rolfing
151
......
Sarah any Howarde George Holt
Registered No.
78
20 UNDERTAKER
Walter Perkan Chelwerd.
5
· DATE OF BIRTH
July
....
60
3
22
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.
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