USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 41
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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) ; Tubcr-
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, ctc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age,". "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
- $ OCCUPATION PARENTS CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very particular kind of work,
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Celingford
(No
Billerica Road
St. :
Ward)
(City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
4
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
Male White
6 SINGLE
MARRIED
the wordy
DATE OF BIRTH July
14
1849
0 8
"Month)
1 AGE 66 . 5
. .....
mos.
28
ds.
or ......... min. ?
(2) Trade, profession, or Tarmer
(b) General nature of industry,
business, or establishment In
which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Sutton, Canada
10 NAME OF
FATHER
Gilbert E. Denne
11 BIRTHPLACE
OF FATHER
(State or country)
Vermont
12 MAIDEN NAME
OF MOTHER
RoxiannaLacey
18 BIRTHPLACE
OF MOTHER
(State or country)
Canada
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ..
Mis. Oliver Natch (daw.)
(Address)
Standich, Mais
16 Filed Jan. 14, 1916 Edward . Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
tan.
.
(Month)
(Day) 11
1916,
(Year)
17
I HEREBY CERTIFY that i) attended deceased from
191
6
to
Jan. 11, 1916;
....
If LESS than
I day .........
........ hrs.
that I last saw himalive on
191.
full
6
......... and that death occurred, on the date stated above, at ....... about 7:30Pm
The CAUSE OF DEATH* was as follows :
acute Lobar Pneumonia
.(Duration) ..
................ mos. . ..... ds.
Contributory.
(SECONDARY)
.......
..... (Duration).
........... yrs.
. .................... ................
.. ds.
(Signed)
M.D. ×1 .12, 19161 (Address) Chehisfirst, Maxs ....
* 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 ............... ............ mos ..
Where was disease contracted, If not at place of death ?.
Former or usual residence .. .............. ..
19 PLACE OF BURIAL OR REMOVAL Fairhaven Cem . Westring mais
DATE OF BURIAL
Han 15, 1916
20 UNDERTAKER
Walter jukan
ADDRESS
Chelmsford.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
?FULL NAME .. [If married or divorced woman or widow give maiden name, also name of husband.] 1 @RESIDENCE
albert Elliott Lenne
une
160 Chelmsford
......
....
....
(Year)
Jan. 6
(Day)
...........
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 dutics 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 employcd, 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 Clic 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 diseasc. Examples: Cercbro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never rc- 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 (sccondary), 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 deathis 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.
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 Lowell Mass ......... (No St. John's Hospital
Ward)
Lowell (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
No. Chelmsford, Mais
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
White
( 5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) Married
6 DATE OF BIRTH
February
24
....
(Month)
(Day)
(Year)
TAGE
If LESS than
1 day .......... hrs.
24 yr
.yrs.
10
mos.
9.17
ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Mill Operation
(b) General nature of industry, business, or establishment in which employed (or employer) ...
@ BIRTHPLACE
(State or country)
Lowell Mars.
10 NAME OF
FATHER
unknown,
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Canada
12 MAIDEN NAME
OF MOTHER
Unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
Canada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Nile
(Address) No. Chelmsford Mass
16 Filed Man, 19, 1916/2
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
January
18
(Month) /
(Day)
1916
(Year)
I HEREBY CERTIFY that
attended deceased from
January 10, 1916
to January 18, 1916
.....
that I last saw hum alive on
18, 1916
and that death occurred, on the date stated above, at 8
gp ....
The CAUSE OF DEATH* was as follows :
acute suppuration appendicitis
(Duration)
.yrs.
mos.
.ds.
Contributory ...
Pulmonary Emboliein
....
(SECONDARY)
.. (Duration)(
.... yrs.
(Signed)
This. P. Welaney
M.D.
Jan.19
1916 (Address).
-
St. John's dorp
٠٠ ......
* 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 REMOYA Chelmsford mars
Stheph
emeleri
DATE OF BURIAL
Jan. 20, 1916
20 UNDERTAKER a archambault
ADDRESS
Lowell
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH. UNFADING INK-THIS IS A PERMANENT RECORD.
vila Talbot
Registered No.
94 5
1891
17
161
.mos. ds.
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 agc. For many occupations a single word or term on the first line will be sufficient, c. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional 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," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who arc engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as 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 rc- 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 discases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, 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. 7000
.....
1
St. :
Ward)
(City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
6
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Lan
(Month)
31
1916
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from Bega, 1915 to Jan 31, 1916. .......... ,
that I last saw hascalive on ... Sau 12, 1916 and that death occurred, on the date stated above, at 10 Pm. The CAUSE OF DEATH* was as follows : Bateria - Selecario
'Duration).
yrs.
mos. ............
ds.
Contributory ..
(SECONDARY)
.. (Duration). .yrs.
.......
.... mos. ..............
ds.
(Signed)
M.D.
FERRI, 196
(Address) 265 Cacaldas 17
* 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. ...... ................. Where was disease contracted, If not at place of death ?... ....... Former or
Usual residence .......... .... ....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
1
20 UNDERTAKER Forma Loben enough.
ADDRESS 176 Sonhando
- --
191 O.
..............................
16 Filed Feb. 1, 1916 Edward, Robbins
...........
REGISTRAR
1 PLACE OF DEATH .. ...... 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE * SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, - 1 OR DIVORCED (Write the word) · DATE OF BIRTH ...... (Month) (Day) 7 AGE C * 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) 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (State or country) 12 MAIDEN NAME OF MOTHER PARENTS 1ª BIRTHPLACE OF MOTHER (State or country) (Informant) Is. Frank Pilley 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 - ........................ y ... .... ....... mos. ds.
9.0
(Year)
If LESS than
I day ........ hrs.
.......... min. ?
---
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
...
162
...........
............................ ....
.........
.......... ......
.......
...
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oeeu- 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- motive engineer, Civil engineer, Stationary fireman, ete. But in many eases, 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 domestie service for wages, as Servant, Cook, Housemaid, etc. If the oeeupation has been ehanged or given up on account of the DISEASE CAUSING DEATH, state oeeupation at beginning of illness. If retired from business, that faet 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 affeetion with respect to time and causation), using always the same aeccpted term for the same diseasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic eerebro-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, ete., 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 (seeond- ary or intereurrent) affeetion need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; 1 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," ete., 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," ete. State cause for which surgieal 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, ete.
2. Deaths supposedly eaused by violenee, 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.
-
1915- 45-
1870-
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
Chelmsford
(No ..
Westford
St. : ;... ............... .. Ward)
Frank Butcher
[If married or divorced woman or widow give maiden name, also name of husband.] aRESIDENCE Hertford St Chelmsford Maca.
Registered No.
7
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Liebe
1.
1916: .......
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from Jose 16, 1916, to Kiel,
fiel1
that I last saw halive on ... , 1916. and that death occurred, on the date stated above, at 100. „.m. The CAUSE OF DEATH* was as follows :
Pneus
--
.. (Duration) ...
mos. 16 ds.
... yrs. .............
Contributory .......
(SECONDARY)
(Duration) ..... yrs.
.. mos, 7
(Signed) ..........
M.D.
..... J
(Address) 276 westhouse
* 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
DATE OF BURIAL
Mestlawn Cemetery Lieb. 4. 1916
20 UNDERTAKER Gro Makale.
ADDRESS
79 Branch lx
......
2 FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male.
4 COLOR OR RACE
White.
[ 5 SINGLE,
MARRIED,
Married.
WIDOWED,
OR DIVORCED
(Write the word)
" DATE OF BIRTH
July 1, 1870.
(Month)
...
(Day)
(Year)
PAGE
45
If LESS than
[ day ......... hrs.
.. yrs. .......
7
.... mos.
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
Teamster.
9 BIRTHPLACE
(State or country)
Nova Scotia .
10 NAME OF
FATHER
John Butcher.
11 BIRTHPLACE
OF FATHER
(State or country)
Nova Scotia:
12 MAIDEN NAME
OF MOTHER
Rosanna Butcher.
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
Nova Scotia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
More Jessie Butcher
(Address) Chelmsford, Mars
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
particular kind of work
Jeameter.
important. See instructions on back of certificate.
16
Filed
Feb. 3. 1916 Edward . Robbins
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
....
/
REGISTRAR
163 Chelmsford.
(City or town.) Elf 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 laborcr, 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, Houscmaid, etc. If the oceupation 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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