USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 39
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Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
no Chelmsford
(No
Middlese
St. :
152 No. Chelmsford you {If death occurred in Ward) a hospital or institution, give its NAME instead of street and number.]
79
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
8 SEX
Male.
4 COLOR OR RACE
White.
5 SINGLE,
MARRIED,
Married
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
Jana
(Month)
(Day)
8. 18.27.
(Year)
7 AGE
If LESS than I day ......... hrs.
88 yrs. 10 mos. 12 ds
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired.
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
Retireds
Hemiplegia
.(Duration) .
.......... yrs.
mos. 20 ds.
Contributory ..
(SECONDARY)
.. (Duration) .
......... yrs.
.mos.
.ds.
JE Varney
M.D.
(Signed)
...
.. 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).
At place
of death.
... yrs.
... mos.
ds.
State ..
.......
In the
.... yrs,
...
mos.
ds.
Where was disease contracted, If not at place of death ?..
Former or usual residence.
19 PLACE OF BURIAL, OR REMOVAL 1%. Take. Waltham, Mace
DATE OF BURIAL
Nov. 22. 1915
20 UNDERTAKER
ADDRESS
79 Branch & #82
1918. 88- 1827-
MARGIN RESERVED FOR BINDING
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
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Mars.
12 MAIDEN NAME
OF MOTHER
Asenath Sawvin
13 BIRTHPLACE
OF MOTHER
(State or country)
Macer
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mira. Lundia As Greenes
(Address) No. Bhelmaffords
15 200.22. 1915 Edward Jobbing
REGISTRAR
16 DATE OF DEATH
Nov.
20.
(Month)
(Day)
1915
(Year)
17
I HEREBY CERTIFY that I attended deceased from
nor 1
. 195 to Our 20
1915
that I last saw ha alive on.
nor 19
1915
and that death occurred, on the date stated above, at 5: 30 Am.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
Ashburnham, Mass.
10 NAME OF
FATHER
Hacea Greener
. .............
.......
--
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
Oliver M. Greene.
2 FULL NAME
.....
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Middlesex 8th No. Chelmsford.
Registered No.
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 fcver (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 more 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.
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 Gast Chelmo Lenovo
2 FULL NAME Margaret ,
[If married or divorced woman or widow
give maiden name, also name of husband, b.
@RESIDENCE
Each Chelmsford Place
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
female Ahito
5 SINGLE,
MARRIED.“
WIDOWED,
OR DIVORCED
AWrite the word)
DATE OF BIRTH
................
(Month)
(Day)
1
(Year)
7 AGE
150
VIS. 5
yrs ..
mos.
ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
mill-operativa
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Lourd mus
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Fyland
12 MAIDEN NAME)
OF MOTHER
fame Connors
13 BIRTHPLACE
OF MOTHER
(State or country)
Jagland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
& Per Chikmalha
16 Filed nov. 24 1915 Edward SoRobbery
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17 I HEREBY CERTIFY that I attended deceased from france 6, 1915 to door 21 1915 that I last saw h ~ alive on. . 1915. and that death occurred, on the date stated above, at 10Pm m. The CAUSE OF DEATH* was as follows : Ipartie Paraplegia
(Duration)
ds.
.yrs.
mos.
Contributory ... (SECONDARY)
(Duration)
.. yrs.
mos.
......
ds.
(Signed)
Jacar RI Ordan
...
M.D.
// 22. 1915 (Address) 295 Centrale
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
... yrs.
. ............ mos.
ds.
State.
..... yrs.
in the
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Do Patriche horas 11/24
........
1917
20 UNDERZAKER
Source
-------
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
153
St. :
............ .. . Ward)
(City or town.) {If death occurred in a hospital or institution, give its NAME Instead of street and number.]
...
80
(Month)
(Day)
21
1910
(Year)
10 NAME OF
FATHER
Patrick Corr
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, 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 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 (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., 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.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 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
1 PLACE OF DEATH Chelmsford
(No. ................. Central Sa St. :
Ward)
2 FULL NAME
Anna Elizabeth Whitbech
[If married or divorced woman or widow
give maiden name, also name of husband.I
G. E. Van Ornan. a. S. Whitbeck
@RESIDENCE
Chelmsford
Registered No.
8%
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
8 SEX
Fem.
4 COLOR OR RACE
ZapisTo
5 SINGLE,
MARRIED,
married
WIDOWED,
OR DIVORCED
(Write the word)
S DATE OF BIRTH
april
15
...
(Month)
(Day)
1854
(Year)
AGE
60
yra.
7 mos. 19
(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)
New York
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Saratoga 11. 4
12 MAIDEN NAME
OF MOTHER
1
1ª BIRTHPLACE
OF MOTHER
(State or country)
new york
L'THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
a. S. Whitech
S. C. P.
(Address)
Chelmsford, mark
Filed
16 DEC-6, 1915 Edward Si Robbins
......
REGISTRAR
.......................... (Duration)
7
.............. yrs.
................ mo8.
......
.ds.
......
Contributory Lemurial Mond pacunng
(SECONDARY)
.(Duration) '
.... yrs.
mos. 10%
ds.
.......
(Signed)
Marshall J. Allein
M.D.
(Address) Forsell, Mean
...........
* 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.
In the
....
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 Pine Ridge Cemetery
DATE OF BURIAL
Dec. 6. 1915
.......
20 UNDERTAKER
Walter Perham
S.C.F
ADDRESS
Chelmsford
mare.
1915
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
hor1, 1915, to Dec itch
1915
....
.................
If LESS than
! day .........
........ hrs.
that I last saw has alive on.
dec, 4th
1915
and that death occurred, on the date stated above, at 9:40Am.
.......... min. ?
The CAUSE OF DEATH* was as follows :
Chronic Pomocarditi
2 ...
10 NAME OF
FATHER
Jacob Van Ornan
* OCCUPATION
16 DATE OF DEATH
December
4th
.....
154
Chelmsford (Ciby or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
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 laborcr, Laborer - Coal minc, 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 homc. Carc should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING 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 discasc. 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 dcad, etc.
:
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX female 7 AGE PARENTS (Address) 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
North Cheluns Ford (No Massachusetts
-
St. :
Ward)
155
......
(City or town.)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Registered No.
82
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH Dee 27
1918-
(Month)
(Day)
(Year)
6 DATE OF BIRTH
December 24
(Month)
If LESS than I day ......... hrs.
... yrs. mos.
C .dš.
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)
north chebus fort, Waso.
10 NAME OF
FATHER
William H. Williams
11 BIRTHPLACE OF FATHER (State or country) Bradford- England.
12 MAIDEN NAME
OF MOTHER
Lily whitaker.
18 BIRTHPLACE OF MOTHER (State or country)
Bradford, England.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
N. 7.1 Williams
16
Filed.
DEC- 22, 1915 Oderand Ysholfing
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
191
Dec 27, 1911
to
....
... .... .
191 .....
that | last saw h -
.... alive on
......
-
and that death occurred, on the date stated above, at 430
The CAUSE OF DEATH* was as follows :
slice. tam
(Duration)
.yrs.
mos.
ds.
Contributory ..
(SECONDARY)
(Signed)
JE Varney
.(Duration)
... yrs.
.mos.
ds.
M.D.
227, 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
of death
... yrs.
In the
mos.
ds ..
mos.
ds.
State ...
... yrs.
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
North Chilies Riverside cemetery
-
DATE OF BURIAL
DEC. 27. 1915
20 UNDERTAKER
ADDRESS
2 chelmsford
MARGIN RESERVED FOR BINDING
€
(Day)
1915 (Year)
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 lino 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 occupation whatever, write None.
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