USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 42
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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, peritonacum, etc., Carcinoma,. Sar- ..
coma, etc., of .. .(name origin: "Cancer" is less definitc; 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
PLACE OF DEATH
Shimstand Mais
(No ) tightand the
St. : Ward)
.... Registered No. 8
PERSONAL AND STATISTICAL PARTICULARS
3 SEX.
Zionale White
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,-
OR DIVORCED
(Write the word)
Engle
DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
If LESS than 1 day ......... hrs.
16
9 ..... mos. 9. ds.
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).
Pupil
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
Thomas Dufly
11 BIRTHPLACE OF FATHER (State or country)
rel
12 MAIDEN NAME , OF MOTHER Marquet. .
18 BIRTHPLACE OF MOTHER (State or country) reland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address) Highland Eve
File
16 Feb. 2 1916Edward J. Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
une
1916 to Jely 2
1916
that I last saw him alive on.
....... 1916 and that death occurred, on the date stated above, at 23,9 m. The CAUSE OF DEATH* was as follows :
Tuberculose
(Duration)
8
............ yrs. .mos. ........... ds. . .........
Contributory ..
(SECONDARY)
(Duration)
............ yrs, . ................ mos. ................ .. ds.
(Signed)
M.D.
Jul 3, 1914 (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.
State ..
.......... y.8. ...........
... mos.
.........
.. ds .........
Where was disease contracted, If not at place of death ?.
Former or usual residence ..
1º PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL.
191.6
20 UNDERTAKER
ADDRESS
1-1
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
164
(City or town.)
fif death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Faul Viitor Fully
....
[If married or divorced woman or widow give maiden name, also name of husband.] aRESIDENCE Do Themstand Plass
...
Month)
(Day)
2º
1916
(Year)
....
....
Fool å
......
PARENTS
at School
important. See instructions on back of certificate.
1
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 oeeupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motivc engineer, Civil engineer, Stationary fireman, ete. 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, ete. 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 oeeupations of persons engaged in domestie serviee for wages, as Servant, Cook, Housemaid, ete. 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 faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oeeu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Cercbro-spinal fever (the only definite synonym is "Epidemie 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, ete., Carcinoma, Sar- coma, etc., of .. ....... ... (name origin: "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (seeond- ary or intereurrent) affeetion need not be stated unless im- portant. Example: Measles (disease eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, sueli as "Asthenia," "An- aemia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shoek," "Uraemia," "Weakness," ete., when a definite disease ean be aseertained as the eause. Always qualify all diseases resulting from childbirth or misearriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ete. State eause 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 Medieal Examiners:
1. Deaths following injury or violenee, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
2. Deaths supposedly eaused by violenee, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ete
4. Deaths under eireumstanees unknown, as A person found dead, ete.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
¿PLACE OF DEATH No Chelmsford (No o north Thelandand Must. ;
........... .Ward)
Bustin & Parkhurst
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
north Chelmyan Mars
Registered No.
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
(Month)
(Day)
6.
1916
(Year)
17 I HEREBY CERTIFY that I attended deceased from 0
1918
· to.
Joly 6'
1916
.......
that I last saw hw alive on
July 5ª
1916
............ ........ and that death occurred, on the date stated above, at 23 pm. The CAUSE OF DEATH* was as follows :
+
Dirbilio
...... ....
about region
(Duration)
............ yrs.
Omos.
.......
ds.
Contributory
... (SECONDARY)
.(Duration)
............. yrs.
.mos.
ds.
(Signed)
M.D.
July 6, 1916 (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.
.......
Where was disease contracted, if not at place of death ?.
Former or usual residence. .......
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Dunstable Mans Fel 9
1916
15 File Seb 6, 1916 Edward & Rabbins
REGISTRAR
12 6.6 1472
8 SEX
Male.
4 COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR-DIVORCED
(Write the word)
-
ghita
/. (Month)
(Day)
7 AGE
46 yrs. 11 mos.
(b) General nature of industry.
business, or establishment in
which employed (or employer) ...
PARENTS
1THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(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
....
......... yrs. ....
17 ds.
Married
1 (Year)
If LESS than
i day ......... hrs.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Spunten Sawyer.
9 BIRTHPLACE
(State or country)
Dunstable Mars
10 NAME OF
FATHER
George. Parkhurst
11 BIRTHPLACE
OF FATHER
(State or country)
Dunstable Mass
12 MAIDEN NAME
OF MOTHER
Amira Parker
12 BIRTHPLACE
OF MOTHER
(State or country)
nashua nt.
(Informant)
Vera Larla Parkhurst
north Chefmand.
ADDRESS
20 UNDERTAKER
David & Greig & son The Hard Way
165 Chefmarad May C(City/or town.) fif death occurred in a hospital or institution, give its NAME Instead of street and number.]
y
PERSONAL AND STATISTICAL PARTICULARS
& DATE OF BIRTH
Fabruraux 19 -1869
....
....
-
......
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, 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 f 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 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" (inerely 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 diseasc, 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.
1!
166
(City or town.)
fIf 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
Anneton IX
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
& SEXTO
+ COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Jingle
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE 85
... yrs. .. ... mos ....
ds.
or ......... min. ?
& OCCUPATION (a) Trade, profession, or particular kind of work.
athome
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
-
10 NAME OF FATHER France Mulligan
11 BIRTHPLACE OF FATHER
PARENTS
LE MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
DElaced
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) (Addres). d.J. Holan
15
Filed. Feb- 9 loft Edward J. Robbing
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
Jan 19, 1916, to.
Feb 9, 1916.
If LESS than
1 day,.
.... hrs.
that Hast saw her alive on.
and that death occurred, on the date stated above, at 120 m. The CAUSE OF DEATH* was as follows :
auteriombroses
.mos. (Duration) 6 .. yrs. ds.
Contributory.
Exposeus touren Feet.
.... (SECONDARY)
.(Duration) yrs. ...
.mos.
21
ds.
(Signed)-
M.D.
(Address).
Tto cheboulard
* 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 DATE OF BURIAL It Tativeki tet.11, 1916
UNDERTAKER PODER E Mollog Inule
5
9
(Month)
(Day)
191_h
(Year)
1
The Commonwealth of Massachusetts STANDARD, CERTIFICATE OF DEATH Francia
St. ....................... Ward)
arm Mulligan
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
......
......
1
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, 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 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," 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," ctc.), "Dropsy," "Exhaustion," "Heart failure,". "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as-A death upon the street, or one supposed~ to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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
Chelmsford! 6>
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Hilda Carbon
Neda andren Dolu 1. Carbon
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
20
5 SINGLE.
MARRIED
WIDOWED,
OR DIVORCED
( Write the Forced
$ DATE OF BIRTH march
14
18.66
(Month)
(Day)
(Year)
7 AGE
If LESS than ! day ........ hrs.
49
_yre. 11 mos.
mos.
0
ds.
... yrs. ....
Or ......... min. ?
· 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)
Sweden
10 NAME OF
FATHER
V
11 BIRTHPLACE OF FATHER (State or country) Sucedeu
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informanty
( dress) West Cliclineand
18
Filed. Feb. 17, 1916 Edward De Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
14
1916
.......
(Month)
(Day)
...... (Year)
17
I HEREBY CERTIFY that I attended deceased from
July 9
196 to July 14
06
that I last saw h alive on ....
July 14
196
and that death occurred, on the date stated above, at 100.
m.
The CAUSE OF DEATH* was as follows :
Deease 1 heart.
/ leaf sekret
6 days
....
.. (Duration)
ds.
.........
Contributory ...
(SECONDARY)
(Duration) ................ yrs. ............
ds.
... mo .. .................
(Signed)
Fred Varney
M.D.
July 16, 1916 (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 ...
ds.
....... yrs.
mos.
....
Where was disease contracted, If not at place of death ?. .............. .... Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
West Cenne wat c
DATE OF BURIAL Feb. 17
6
191
........
ADDRESS
20 UNDERTAKER
Walter Certam
44am
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
PARENTS
4
2 FULL NAME. [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE West Chelmsford mare
St. ; .Ward)
.....
....
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, ete. 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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