USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 40
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56
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, peritoneum, 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 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.
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
No Chehurford
.(No
trials
91
St. ;
................... Ward)
harles H. Crowell
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husoand.]
@RESIDENCE
Wright So No 6 helmafar de
Registered No.
83
PERSONAL AND STATISTICAL PARTICULARS
0
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
marrua
· DATE OF BIRTH
Selv 29
(Month)
(Day)
1849 1 (Year) frey
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)
Intry) Fundondung Noth
PARENTS
12 MAIDEN NAME
OF MOTHER
Munich Ifatti
18 BIRTHPLACE OF MOTHER (State or country)
Nar
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16 DEC.31, 1915 Edward d. Bobbing
REGISTRAR
.........
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from 1915, to ......
Dec 31
1911
......
that I last saw ha alive on Dec 31
and that death occurred, on the date stated above, at 830 %.
The CAUSE OF DEATH* was as follows):
Interactive
(Duration) / yrs.
.mos.
de.
Contributory ..
(SECONDARY)
....
{Duration) .. ............. yrs. ............. mos. ds.
(Signed)
Dec 31.
191 ... " (Address) .....
M.D.
....... .....
* 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.
Stato ............ yrs.
............ mos.
....
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Parmar Cemetil
DATE OF BURIAL
lan 3
....
1915
20 UNDERTAKER
How good Blake
1
ADDRESS
3.3 Piccante
156
........
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
16 DATE OF DEATH
Dec 3/
1915
7 AGE
If LESS than
1 day ......... hrs.
6.6
yrs. 3
mos.
„ds.
10 NAME OF
FATHER
David Crowell
11 BIRTHPLACE OF FATHER (State or country)
.
-
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 cxamples: (a) Spinner, (b) Cotton mill; (a) Salcs- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may forin 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 (retircd, 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 samc disease. Examples: Ccrebro-spinal fcver (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," unqualificd, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. ....... .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," " "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc
4. Deaths under circumstances unknown, as A person found dead, etc.
- --
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. Boston Road
St. :...
.Ward)
...........
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
0. Martha Ellen Radium 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford mas
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
60
5 SINGLE,
MARRIED
WIDOWAD,
Dercale
.
(White the word)
i DATE OF BIRTH
Cham.
20
.
(Month)
(Day)
(Year).
/
If LESS than
1 day ......... hrs.
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) ...
S BIRTHPLACE
(State or country)
10 NAME OF
FATHER
Nathan P. Dadummy
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Celearles toun
12 MAIDEN NAME
OF MOTHER
Martha Laws
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Guard Hade
(Address)
15 Filed. Jan 3, 1916 Edward J. Bobbing
-REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
January
2
(Monthy
(Day)
1916
(Year)
17
I HEREBY CERTIFY that I attended deceased from
6
november, 1915, to Jul 2
191
....
....... )
that I last saw her alive on
Law 2 196
and that death occurred, on the date stated above, at ........... m.
The CAUSE OF DEATH* was as follows :
arterio Ichlersão
7
(Duration) .
................. yrs.
.............
..............
.. mos ..
.. ds.
Contributory.
Femural Broncho Phone
(SECONDARY)
.(Duration)
................ yrs.
.... mos.
ds.
M.D.
(Signed)
Jac 3, 1916 (Address) Someil mars
........
* 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.
ds.
Where was disease contracted, If not at place of death ? ... Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
Forefathers Cem,
lelunsford
DATE OF BURIAL
Jan. 4
6
191
....... ,
20 UNDERTAKER
Walter Tenham
ADDRESS
Chelmsford.
....
" AGE 67
.yrs.
mos.
ds.
or ......... min. ?
157
(City ertown.)
.........
...
1916
-
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 NEATH, 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 nIs- EASE CAUSING NEATH (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 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 Cheenfance .(No Gratin Road St.
John F. Callahan
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of busband.] @RESIDENCE Frutos Rd. Cheleashed
PERSONAL AND STATISTICAL PARTICULARS
3 SEX male
4 COLOR OR RAGE white
6 SINGLE MARRIED WIDOWED OR DIVORCEY CY Our (Writethe word)
6 DATE OF BIRTH
7 AGE
57
... yrs.
mos. ds.
or ........ min. ?
8 OCCUPATION Malconay Enquan
(a) Trade, profession, or particular kind of work
(b) General nature of Industry, business, or establishment in which employed (or employer).
Warten fail
9 BIRTHPLACE
(State or country)
") Found mass
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or country) leland
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
Lucland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) John& allahan, cour
15
Filed. Jan. 10, 1916 Edward S. Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH Jan. 9 Day)
(Montlı)
191.6
(Year)
17
I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
Dieaus of the thart
(Duration)
yrs ..
mos. ds.
Contributory .. (SECONDARY)
.mos. ds.
(Duration) IV. neige
M.D.
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATII, or, in deaths from VIOLENT CAUSES, state (!) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL OF HOMICIDAL.
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 diseaso contracted, if not at place of death ?. .... Former or usual residence ..
19 PLACE OF BURIAL OF REMOVAL Afetada Cemetry
.......
DATR OF BURIAL Jan 11. 196
ADDRESS
158 Chelmln)
Ward)
(City or towy.) {If 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.
(Month) (Day)
! (Year)
if LESS than I day ......... hrs.
(Signed)
Jan 10
191 ....... (Address).
(Address) nel dunford Pass 7 10 UNDERTAKER
Registered No.
2
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preeise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean 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- molive 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, cte. 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 indieated 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, meningcs, peritonaeum, ete., 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, ete. 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 symptomatie), "Atrophy," "Collapsc," "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 aseertained 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. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound cf head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."
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, ete.
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 cireumstanees unknown, as A person found dead, ete.
R. 16-8-'15. 5,000.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
- 3 SEX Female TAGE PARENTS important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ....
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH mit (helvioford ......... (No.
... ...
St. :
.Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Homes Margaret Comuns
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Church t
.... Forth Cheles ford Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH Jau 9
(Month )
(Day)
1916
(Year)
17
I HEREBY CERTIFY that I attended deceased from
6.
Jan 3, 1914, to.
for 10,
191
that I last saw her alive on Jan am 10, 1916. and that death occurred, on the date stated above, at 5: 45Pm. The CAUSE OF DEATH* was as follows :
Malnutrition
(Duration)
......
yrs.
mos.
35 de.
Contributory
(SECONDARY)
.(Duration) ..... yrs. .......... ... mos. ....
.......
.. ds.
(Signed)
Lame flatan
.......
M.D.
Sam 10, 19 (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 ?.
Former or usual residence. .... .....
19 PLACE OF BURIAL OR REMOVAL
(Informant)
(Address) Anth Chelwar ford
16 Filed .... 1.10 1916 Edward Rolfing
REGISTRAR
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Viegls
· DATE OF BIRTH
.......
(Month)
6 1916 (Day) (Year)
If LESS than I day ......... hrs.
-
yrs. .......
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)
North Cheluisand
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
Geabody Mass
12 MAIDEN NAME
OF MOTHER
Vadu Q. Leahy
13 BIRTHPLACE
OF MOTHER
(State or country)
Worth Chelefond
14 THE ABOVE IS TRUE, TO THE BEST OF MY KNOWLEDGE
DATE OF BURIAL
Jan 10 1916
20 UNDERTAKER
ADDRESS
159 hlubo ford ........
......
3
4 COLOR OR RACE
13
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, Laborcr - 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.
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.