USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 44
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 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 discase; 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.
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 Commmiwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. Grove It
...........
St. :
.............
.Ward)
7 enry Taisen (Stubborn)
2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RÉSIDENCE
PERSONAL AND STATISTICAL PARTICULARS
& SEX m
4 COLOR OR RACE
w
5 SINGLE,
MARRIED,
WIDOWED, ,
OR & FORCED
KW rite alle totale
16 DATE OF DEATH
March 14
1916
(Month)
(Day)
(Year)
· DATE OF BIRTH
march 140 1916
(Month)
(Day)
(Year)
7 AGE
If LESS than
[ 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)
Chelmsford
PARENTS
12 MAIDEN NAME
OF MOTHER
Florence Stuart
13 BIRTHPLACE
OF MOTHER
(State or country) Nova Scotia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
( Address)
Filed Mar. 14, 1916 Edward Robbing .......
REGISTRAR
............
....... .................. .......
(Duration) 2 ....... yrs.
.mos.
....... ds.
(Signed)
Huhu 9, colonia
M.D.
Mar 16. 19
1916
(Address).
Chelmsford, masa
* 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
In the
RECENT RESIDENTS).
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 tawn leur.
DATE OF BURIAL
may, 16
1916
.......
20 UNDERTAKER
Walli Pulam
ADDRESS
Clubunfond.
172
..............
(Citylor town.) fif death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
16
MEDICAL CERTIFICATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
Mar. 14, 191 6,
Mae 14, 1916
that I last saw h ............. alive on
191
........
and that death occurred, on the date stated above, at.
.....................
The CAUSE OF DEATH* was as follows :
.(Duration).
...
.. yrs. .................. 08. ...
....
ds.
Contributory ...
(SECONDARY)
10 NAME OF
FATHER
Leon de Taires Dr.
11 BIRTHPLACE OF FATHER (State or country) Canada
MARGIN RESERVED FOR BINDING
A
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, Houscwork, 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 lias 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 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 indefinitc); 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.
1
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX Jemals 7 AGE 10 NAME OF FATHER PARENTS important. See instructions on back of certificate. 1$ 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 Anth Cheloxford (No. Meddler
Catherine
The manumm
Catherine M: manus laws Mi mammon
Registered No. -17
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
Mate
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Pedro
& DATE OF BIRTH
-
1848
(Month)
(Day)
(Year)
If LESS than
{ day .......... hrs.
69
-
1
mos.
ds.
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)
11 BIRTHPLACE OF FATHER (State or country)
Nuland
12 MAIDEN NAME OF MOTHER Pargaut
18 BIRTHPLACE OF MOTHER/ (State or country)
Quelaund
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE run the
(Informant).
Miso alece mi manunem
(Address)
forth Cheles ford
Filed tel. 15 jeg 6 Edward F. Robbins
REGISTRAR
fort
Cheli 173 ford
(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
meddling Street. but! Cheleford
MÉDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
fil march-5
(Month)
(Day)
1916
(Year)
17
I HEREBY CERTIFY that I attended deceased from Feb 15, 1916, to Mari 4, 19/6. .... that I last saw her alive on Mary, 196 and that death occurred, on the date stated above, at ) 9, ... m. The CAUSE OF DEATH* was as follows :
Chroni Nehbuti
Sente Dibility
... (Duration)
3
.yrs.
Contributory ......
Criteria calerosis
mos.
ds.
...
(SECONDARY)
(Duration) .
... yrs.
.... mos.
ds.
James Italien
.....
M.D.
Mar 5 1916
(Address)
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
In the
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death.
.yrs.
. ...
.mos.
.ds.
State.
.. mos.
ds ..
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
F. Patur Ce
9 nues
DATE OF BURIAL
man T.
1916
-
20 UNDERTAKER
ADDRESS
---------
St. : Ward)
......
(Signed)
.......
.yrs.
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, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. . .(namo 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.
R. 15-8-'15. 100,000.
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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No
Golden Cove Road
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Murielmaler Houve
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
march
20
6 .......
(Month)
(Day)
.....
(Year)
6 DATE OF BIRTH
24
1913
.......
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day ......... hrs.
2
.........
y. 2
.mos. ..
225ds.
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)
try) Quincy mass
.(Duration) .
.............. yrs.
mos.
10
.ds.
Contributory
Infections Zano, nose preluat
.. mos.
....
(SECONDARY)
.. (Duration)
.... yrs.
10
ds.
(Signed)
Marshall 2. villing
...
M.D.
march20, 1916 (Address) Enese Made
..............
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
.... yrs.
... mos. ......
ds.
State.
.yrs.
In the
mos.
ds ..
...
Where was disease contracted, If not at place of death ?.
Former or usual residence
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
202.9. Howe
(Address)
18 Filed Mar. 21 1916 Edward S. Robbing
....... REGISTRAR
....
17
I HEREBY CERTIFY that I attended deceased from March 11, 1916, to march 20, 1916 that I last saw her alive on march 19, 1916. and that death occurred, on the date stated above, at 6:36am. The CAUSE OF DEATH* was as follows :
Scarletfever ........
...........
10 NAME OF
FATHER
Joseph 9. Hows
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
New Brunswick
12 MAIDEN NAME
OF MOTHER
Ferie Townshend
18 BIRTHPLACE
OF MOTHER
(State or country)
England
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Edson Com Loade March 21, 1916
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
3 SEX
Itemale
4 COLOR OR RACE
white
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
7
18
Registered No.
174 Chelmsford ... (City or town.)
important. See instructions on back of certificate.
......
......
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. Carc should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Namc, first, the DIS- DASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. „(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mcrely 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," 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
175 Jourle (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No. 19
1916. (Year)
....
I HEREBY CERTIFY that I attended deceased from
.......
191 ...
........ , to.
Mar.19, 1916.
that I last saw het alive on March 19 96
and that death occurred, on the date stated above, at ............
.(Duration).
ds.
.............. yrs. ..............
... mos ..
.........
Contributory
(SECONDARY)
....
.... (Duration
................ yrs. ................ mos.
...................
M.D.
Mar. 23, 1916 (Address)
.....
Chelmsford man.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death.
.. yrs.
.mos.
ds ......
.......
Where was disease contracted, If not at place of death ? .... usual residence. ...........
DATE OF BURIAL Edson Cemetery March 24, 1916
20 UNDERTAKER Simmons & Sabun $/ /gia
DRESSauch St. gowell Mass
.......
REGISTRAR
STANDARD CERTIFICATE OF DEATH 1 PLACE OF DEATH Chelmsford Mars (No Chelmsford Ward) St. : ...... Juliet Putney 2 FULL NAME [If married or divorced woman or widow Juliet, Jebbits Walter Putney give maiden name, also name of husband.] @RESIDENCE Chelmsford Mass PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH 3 SEX 5 SINGLE, 16 DATE OF DEATH Mar. Windows (Month) 22 (Day) temale 4 COLOR OR RACE White WIDOWED, OR DILOROED (Write the word) ..... · DATE OF BIRTH 17 - (Month) (Day) (Year) If LESS than 7 AGE 1 day ......... hrs. 81 ...... .. mos. .ds. or ......... min. ? 8 OCCUPATION (a) Trade, profession, or particular kind of work .... It home The CAUSE OF DEATH* was as follows : Cancerroma (b) General nature of industry, business, or establishment in which employed (or employer). 9 BIRTHPLACE (State or country) Holderness IN H. ...... 10 NAME OF FATHER Dames Lubbitte (Signed) Anten y Seabona 11 BIRTHPLACE OF FATHER (State or country) Centre Harbor M. H. 12 MAIDEN NAME OF MOTHER PARENTS ds. State .... .. mos. In the ............ yrs. 1ª BIRTHPLACE Centro Harbor n. H. OF MOTHER (State or country) Former or " THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE (Informant) Mrs Sva 3. Outnay 19 PLACE OF BURIAL OR REMOVAL 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. (Address) Chelmsford Mass 15 Filed Inav. 22, 196 Edualt + Rating N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state ..............
--
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.