USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 45
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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 usc of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tubcr-
1
1
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. . .(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
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.
Lowell Hospital
176
Lowell
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Gladys Ray Howe
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford, Mass.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
4 COLOR OR RACE
W .
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
· DATE OF BIRTH
April 10, 1912.
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
1 day ........ hrs.
3
11
11
.. mos.
ds.
or ......... min. ?
B 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)
Quincy, Mass.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
St. John, N. B.
12 MAIDEN NAME
OF MOTHER
Jennie Townsend
18 BIRTHPLACE
OF MOTHER
(State or country)
England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Father
(Address)
Chelmsford, Mass.
16 Mar. 24 -
Filed.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
March 23.
1916
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
Mar.
21,
191 6
Mar. 23.
6
191.
..........
that I last saw her alive on ..
Mar. 23
191.
6
and that death occurred, on the date stated above, at.
.......
.... m.
3.25P.
The CAUSE OF DEATH* was as follows :
Scarlet Fever
(Duration)
.yrs.
mos. ds.
Contributory
(SECONDARY)
(Duration)
.............. yrs.
... mos. ....... ds.
(Signed)
E. J. Clark
M.D.
.....
Mar. 24 ,6 (Address)
Lowell Hospital
....
* 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 ..
...
19 PLACE OF BURIAL OR REMOVAL
Edson Cem.
DATE OF BURIAL
Mar. 24
6
191
........
20 UNDERTAKER
W. Perham
ADDRESS
Chelmsford
...
St. :...
............
Ward)
20
Registered No. 494
Female
......... yrs.
------
10 NAME OF
FATHER
Joseph J. Howe
....
to
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 cach 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 enginccr, 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 necded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housc- 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 Nonc.
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 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 eause 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 onc supposed to be due to Alcoholism, ctc
4. Deatlıs under circumstances unknown, as A person found dead, etc.
R 18. 3-'16. 10,000.
-
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
177 No. Chelmsford (City or town.)
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
North Chelmsford (No
St. ;....................
.Ward)
C
Ford ( No
[If death occurred in
Winnifred Lucia Polly
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
North Chelmsford
Registered No. 21
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
5 SINGLE,
MARRIED
.
WIDOWED,
OR DIVORCED
(Write the word)
White
16 DATE OF DEATH
abril
5
1916
(Day)
(Year)
........
(Month)
& DATE OF BIRTH
17
I HEREBY CERTIFY that I attended deceased from
-
(Month)
(Day)
(Year)
mar 26th
.. 1916, to abril 4KL 196
7 AGE
If LESS than
I day ......... hrs.
that I last saw hex alive on.
abril yk, 196
.....
26
.yrs.
11
mos.
„ds.
........ min. ?
and that death occurred, on the date stated above, at ................... m.
& OCCUPATION
(a) Trade, profession, or
particular kind of work
at home
The CAUSE OF DEATH* was as follows :
Hubmonay Tuberculose
·
(b) General nature of Industry,
business, or establishment In
which employed (or employer).
9 BIRTHPLACE
about
(State or country)
Westford Mass
mos.
ds.
(Duration) ............... yrs.
....
Contributory ....
(SECONDARY)
10 NAME OF
FATHER
Robert W Pulley
.. (Duration).
............... yrs.
.. mos.
.......
(Signed)
........
M.D.
... ds.
..............
11 BIRTHPLACE
OF FATHER
(State or country)
North Chelmsford
.... .
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
12 MAIDEN NAME
In the
OF MOTHER
Grace adelaid Puto
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
PARENTS
At place
death
yrs.
. mos.
. ....
ds.
State ...
... yrs.
mos.
ds.
....
Where was disease contracted,
pot at place of death ?.
18 BIRTHPLACE
OF MOTHER
(State or country)
Chelmsford Marcos
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Former or
usual residence.
(Informant)
Mr Robert Poller
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
North Chelmsford Edson Cemetery april
important. See instructions on back of certificate.
(Address)
191
0
permiten
20 UNDERTAKER
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
............
1916 (Address) 226 Euromack or
15 Cfr. 7. 1916 Edward . Robbing
REGISTRAR
Simmons & Brown 96 Branch St Lowell
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 reccive 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 discasc. Examples: Cercbro-spinal fcver (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," unqualificd, is indefinite): Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .............. ........... „(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Wcakness," 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 strcet, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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
important. See Instructions on back of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
No Chelmsford Mass (No. Wright St St. :
.......
Ward)
(City or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME TUOY A Crowell [If married or divorced woman or widow give maiden name, also name of husband.] TUcv Movi Charles HI Crowell
@RESIDENCE
Wright St No Chelmsford Mass
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
¿ SEX
Female
' COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
Vi low
OR DIVORCED
(Write the word)
· DATE OF BIRTH
Sant 785]
-
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day .......... hrs.
64 ...... yrs. ....... .....
.mos.
ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
At Home
particular kind of work
......
(b) General nature of industry, business, or establishment In which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Billerica Mass
(Duration)
yrs.
mos.
... ... ds.
Contributory ..
(SECONDARY)
(Duration)
.. yrs.
mos.
.. ds.
(Signed)
7 EVarney
M.D.
april 10. 10
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.
. ...
ds ...
Where was disease contracted, If not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
Corner Cemetry
Billerica
DATE OF BURIAL
Apr 11
1916
(Address)
Feverray Hand
16 Ohr, 10, 1916 Edward & Robbing Filed
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
Mich no
... 1916, to
april 8h
1916
..............
.......... .......... that I last saw h~ alive on april 8. 1916 and that death occurred, on the date stated above, at 1145 Pm. The CAUSE OF DEATH* was as follows :
Prenosenia
...
10 NAME OF
FATHER
Daniel Floyd
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Wermnot
12 MAIDEN NAME
OF MOTHER
Susan M. Bushee
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Harry A Crowell
20 UNDERTAKER
Card
ADDRESS- 3.3(riscal Dx .
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
178.
No Cheins for1
....
Registered No.
22
.........
(Month)
(Day)
(Year)
16 DATE OF DEATH
Abril 8 1916.
191
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, 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 necded. As examples: (a) Spinner, (b) Cotton mill; (a) Salcs- man, (b) Groccry; (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 wagcs, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state oceupation 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: Cerebro-spinal fever (the only definite synonyın 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, 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, ete. The contributory (seeond- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (disease eausing 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," "Wcakness," 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 Medieal Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly eaused 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, ete.
1
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate. N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
No. Checksford
(No
Groton Road
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Walter n. Marinel fr.
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Groton
Road, No. Chelmsford
Registered No. 23
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
Single
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
april
(Month)
10.
1916 (Year)
7 AGE
If LESS than 1 day ......... hrs.
... yrs.
/
mos.
X
„ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ...
none
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
none
9 BIRTHPLACE
(State or country)
no. Chelmsford mars
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
no. Chelmsford, Mare
12 MAIDEN NAME
OF MOTHER
amelia Syret
13 BIRTHPLACE
OF MOTHER
(State or country)
Jevany Island England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Walter n: marinel
(Address)
220. Chelmsford Mare.
15 Filed apr. 15, 1916 Edward . Rolfony
REGISTRAR
17
...
I HEREBY CERTIFY that I attended deceased from
april 10
april 14
191 6
.......
1916 to.
....... ,
........
.... .
that I last saw him alive on ..
april 14
1916
and that death occurred, on the date stated above, at 7 0 m.
The CAUSE OF DEATH* was as follows :
2 cterra
.(Duration)
.............. yrs.
......
mos ..
......
.ds.
Contributory ...
(SECONDARY)
... (Duration) ....
.mos.
.ds.
(Signed)
Fred E Jamey
M.D.
april 14.196
*Uf 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
Gs.
State ............ yrs.
............ mos.
......
CS ...........
Where was disease contracted, if not at place of death 7.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Riverside Cemetery no. Chelansford & mass.
DATE OF BURIAL
april 15, 1916
20 UNDERTAKER
George W. Healey
ADDRESS
ABranch St.
--
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
april
14
.
1916
....
...
(Month)
(Day)
(Year)
(Day)
179 no. Chelmsford (City-or town.)
MARGIN RESERVED FOR BINDING
10 NAME OF
FATHER .
Walter n. Marissal
.
...........
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 nceded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, 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 homc, 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 (rctired, 6 yrs.). For persons who have no occu- pation whatever, write None.
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