USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 43
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 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," unqualificd, is indefinite); Tuber-
culosis of lungs, meninges, peritonacum, 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 (sccond- 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 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 dcad, ctc.
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 South Chelmsford
......
Samuel H. Vedcham
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Youth Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Fieb.
14
(Month)
(Day)
1916 (Year)
I HEREBY CERTIFY that I attended deceased from
1911 totel 10
1916
2.,
..........
that I last saw had alive on ...
16.10
1916
and that death occurred, on the date stated above, at 159 m.
The CAUSE OF DEATH* was as follows : Cerebral bemontage.
(Duration)
yrs.
... mos .. ds.
Contributory ... (SECONDARY)
.(Duration) ........... yrs.
.mos.
.. ds.
(Signed)
M.D.
Kel N, 196 (Address) 408 middlecy 88
* If death followed injury or violence the certificate of death must be made ont 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. ........
...............
Whero was disease contracted, If not at place of death ?.
Former or usual residence .. .............
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Harvard, Maso
Filed Freb. 16, 1916 Edward X. Bobbing
REGISTRAR
168
(City or town.)
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
$ SEX
& SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
Male
4 COLOR OR RACE
I hate
· DATE OF BIRTH
(Month)
(Day)
7 AGE
78
L
6
mos.
ds.
& OCCUPATION
Retired
(a) Trade, profession, or
particular kind of work.
(b) General nature of industry,
business, or establishment In
which employed (or employer) ..............................................*****!!!
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
..............
yrs.
important. See instructions on back of certificate.
(Address)
16
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
......
If LESS than I day ......... hrs.
or ......... min. ?
+
9 BIRTHPLACE
(State or country)
)Haverhill, Mass.
(Year)
Registered No.
12
....
............................................................................................
......
(Informant) &
Henry E. Badger
ADDRESS
20 UNDERTAKER Zeny Jaun des Korvel. Mas
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 eaclı 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. - Namc, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted terin for the same discasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) : Tuber-
culosis of lungs, meninges, peritonaeum, etc., Careinoma, 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" (mcrely 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 for- 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
1 PLACE OF DEATH howell mas No ... Lowell Gen Hospital St
Still Born ( Wecosta)
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Philmotore Centre mass.
13
Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
February
15
6
191.
(Month)
(Day)
.,
(Year)
I HEREBY CERTIFY that I attended deceased from
...........
191.
........ , to
191.
.........
...
that I last saw h .............
alive on.
191-1
and that death occurred, on the date stated above, at ..
.... m.
The CAUSE OF DEATH* was as follows :
Still Born
(Duration) . ... yrs. ....
mos.
ds.
Contributory
(SECONDARY)
(Duration) ........
Ayrs. 1
.. mos.
„ds.
(Signed)
arthur G. Acolovía
M.D.
Feb, 19, 1916
.....
( Address).
Chelmsford Mass
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death.
... yrs. ............ mos.
ds.
. ....
State.
.......... yrs.
.... mos. .....
ds
Where was disease contracted, If not at place of death ?..
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
St. PatrickCemetery Feb. 21.
16 Feb, 23, 1916 , som
REGISTRAR
169
Lowell
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
male White
5 SINGLE,
MARRIED,
Single
WIDOWED,
OR DIVORCED
(Write the word)
" DATE OF BIRTH
February
57
(Month)
(Day)
" AGE
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)
Lowell Mass.
10 NAME OF
FATHER
Joseph hecosta
11 BIRTHPLACE
OF FATHER
(State or country)
Portugal
12 MAIDEN NAME
OF MOTHER
Rose august
PARENTS
13 BIRTHPLACE
OF MOTHER
Portugal
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
father
important. See instructions on back of certificate.
(Address)
Chelmsford Ct. mars
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 ....
mos.
ds.
or ........ min. ?
1916 17
(Year)
If LESS than
I day .......... hrs.
,
20 UNDERTAKER
J. J.6 Connell
ADDRESS
6 58 Gorham St.
......
1 1916 .......
....
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. -- Precise statement of occu- pation is very important, so that the relative healthfulncss of various pursuits can be known. The question applies to eachı 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 naturc of the business or industry, and therefore an additional linc is provided for the latter statement; it should be used only when necded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. Thc material worked on may form part of the second statement. Never return "Laborer," "Forcman," "Manager," "Dealer," etc., without more precise specification, as Day laborcr, Farm laborer, Laborer - Coal mine, etc. Women at home, who arc engaged in the dutics of the houschold only (not paid House- keepers who receive a definite salary), may bc entercd 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 (nover rc- port "Typhoid pncuinonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, 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 (sccond- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure,". "Haeinorrhage," "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 causc 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, ctc.
4. Deaths under circumstances unknown, as A person found dcad, etc.
..
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
170
1
STANDARD (CERTIFICATE OF DEATH
....
1 PLACE OF DEATH
Chelmsford
St. ;...................
IN Marvell Street
Ward)
(City dr town.)
[if death occurred in
a hospital or institution,
give its NAME instead
......
Jamie Caroline adams.
Tami
of street and number.]
'FULL NAME
...
[If married or divorced woman or widow
Joseple E. adama.
give maiden name, also name of husband .!
@RESIDENCE
Chelmet
Registered No.
14
6
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
+ COLOR OR RACE
(Month)
While
& SINGLE
MARRIED,
16 DATE OF DEATH
24
Fel
WIDOWEN
OR Divorce preich
7
(Write the wo
(Day)
(Year)
191
" DATE OF BIRTH
October 12
1544
17
I HEREBY CERTIFY that I attended deceased from
(Month)
(Day)
(Year)
1914
.......... , 191.
If LESS than
....
1916
I day .........
........ hrs.
to
Feb 24
1916
AGE
71 via 4 / 12
that I last saw her
alive on
ds.
......
or ......... min. ?
and that death occurred, on the date stated above, at 9 9, m.
.... mos.
...........
.yrs. ........
& OCCUPATION
The CAUSE OF DEATH* was as follows :
(a) Trade, profession, or
particular kind of work
at home
Broncho precuma
(b) General nature of Industry,
business, or establishment in
which employed (or employer) .......
9 BIRTHPLACE
(State or country)
.. (Duration) ...
........... yrs.
.............
.. mos. ..
.. ds.
Pelham N.H.
Contributory ............
Bunchof antheres yeurploy eur
10 NAME OF
(SECONDARY)
FATHER
Franklin 7 Pearl
.(Duration).
7
.......
.... yrs.
... mos.
.......
ds.
(Signed)
M.D.
..................
........
....
11 BIRTHPLACE
OF FATHER
191 ........
(Address).
(State or country)
N.H.
* If death followed injury or violence the certificate of death must he made
out by the Medical Examiner.
12 MAIDEN NAME
OF MOTHER
Caroline Q. Howard
1$ LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
PARENTS
At place
In the
of death
yrs.
.... mos.
ds.
State ....
......... yrs.
... mos.
13 BIRTHPLACE
OF MOTHER
IV. +
(State or country)
Where was disease contracted,
If not at place of death ?.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Former or
usual residence.
(Informant)
Soluble E adam
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
(Addres) Chebu Stur. Yine
Feb. 26
1916
important. See Instructions on back of certificate.
.....
16
Filed Feb. 26, 1916 Edward . Rabbiny
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
..............
REGISTRAR
20 UNDERTAKER
ADDRESS
Walter Tecken, Chilufund.
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. - Namne, 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 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, 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 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 dead, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
3 SEX - PARENTS 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 .......
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Clickenstund
.(No
Billenia Road
Chelicitud 7
............
(City or vofyn.) [if death occurred in a hospital or institution, give its NAME instead of streat and number.]
anna S
magnum
'FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
w-
5 SINGLE
MARRIED?
WIDOWED
OR DIVORCED down
(Write the word)
* DATE OF BIRTH
abril
25
(Month)
(Day)
1824
(Year)
7 AGE
91 yrs. 10
... yrs .....
6
„.mos.
ds.
or ......... min. ?
* OCCUPATION
(a) Trada, profassion, 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)
England.
10 NAME OF
FATHER
James Starfrels
11 BIRTHPLACE
OF FATHER
(State or country)
England
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
England
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
James W. Lowg.p
18 Filed mar, 2, 1916 Edward Do Rotting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
March 2 196;
.........
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Firb. 9
1916 to
Molar, 2 1916
....
.......
........... ,
that I last saw h 14 alive on.
March 2016
.......
and that death occurred, on the date stated above, at ..................... m. The CAUSE OF DEATH* was as follows : Impacted Fracture of Right
Femur -
accidental try fall
Senilite
(Duration)
.. yrs.
mos.
ds.
Contributory ..........**********!!
(SECONDARY)
(Duration)yrs ..........
... mos.
ds.
(Signed)
Antun 1, colonia
M.D.
Mast, 1916. (Address) Brancheford, Mars
.......
* If death followed injury or vioience the certificate of death must be made out by the Medicai Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At placa
of death ...
yrs.
.... mos.
... ds.
State ............ yrs.
mos. ...
.. ds ... .......
Where was disease contracted, If not at place of death ?.
Former or usual residence. ...... ...
19 BLACE OF BURIAL OR REMOVAL well Cemetin
DATE OF BURIAL
Pas. 5
6
191
well, mars
ADDRESS
20 UNDERTAKER
Walter Tenham Chelmsford
St. ;........................ Ward)
....
Uma S. Starkels Henry Mayoun
Registered No. 15
.............
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 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.