USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 46
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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 fevcr (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" (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, cte
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 Male 1 AGE PARENTS 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
Chelmsford
(No.
Boxton Road
St. :...
................ Ward)
Herbert Havelock Stackhouse
2 FULL NAME
[ If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
........
....
Registered No.
24
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
married
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
Due 25
(Month)
(Day)
(Year)
If LESS than
! day ......... hrs.
40
3 mos. 21 ds.
mos.
...... yrs.
or ......... min. ?
* OCCUPATION
(a) Trade, profession, or
particular kind of work.
...........
Carpenter
(b) General nature of Industry, business, or establishment In which employed (or employer) .. ......
9 BIRTHPLACE
(State or country)
Salt Springs Theo Brunswick
10 NAME OF
FATHER
My Stackhouse
11 BIRTHPLACE
OF FATHER
(State or country)
Mathias Maine
12 MAIDEN NAME
OF MOTHER
Mary Schofield
1$ BIRTHPLACE
OF MOTHER
(State or country)
Canada
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mure Haber
(Address)
Chelmsford
16 apr. 16. 1916 Edward Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
apr.
(Month)
(Day) 15
1916
(Year)
17
I HEREBY CERTIFY that I attended deceased from
apr. 12. 1916.
to
apr.15
1916
that I last saw home alive on
apr. 15
.. 1916
and that death occurred, on the date stated above, at.
... m.
The CAUSE OF DEATH was as follows :
Cerebral Pharmaton
-
...................................................
:
1
.yrs.
(Duration)
.ds.
......
Contributory ..
(SECONDARY)
(Duration)
.... yrs.
.................
. ............... mos.
de.
M.D.
(Signed)
apr. 16. 1916. (Address).
Chilemotril mars
* 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 ....
............. ..........
......
..... mos. .......
ds ....
Where was disease contracted,. if not at place of death ?.
Former or usual residence. ............. .................................. ........
19 PLACE OF BURIAL OR REMOVAL
Pine Ridge Ceno
20 UNDERTAKER
M. Perhan
ADDRESS
Chelasford
180 Chelmsford
..........
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
· COLOR OR RACE
white
1875,
........
......
..........
.................
....
DATE OF BURIAL
april 18
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 cvery 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- kecpers 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 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," "Collapsc," "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 discase, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
... (No Sonham
St. :
Ward)
(Ofty or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
17 1916
(Year)
If LESS than
1 day ......... hrs.
or ......... min. ?
9 BIRTHPLACE
(State or country)
Helow fod Mas
Lahaus
11 BIRTHPLACE OF FATHER (State of country) Queland
12 MAIDEN NAME OF MOTHER Beurs Sovill 81
14 THE ABOVE ISTRUE TO THE BEST OF MY KNOWLEDGE
ther
(Address) For haus S. Chelwater mars
16
Filed. Cfr. 17, 1916 Edward , Rafting
REGISTRAR
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
April 17, 1916, to
Afut 17. 1916
that I last saw ham ative on.
dur 796
.........
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)
.... yrs.
mos.
ds.
(Signed)
M.I Mechan
M.D.
Jul 19,166 (Address).
928 Farther DI.
...........
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death
.. yrs.
In the
...
... mos. ....
.. ds.
State ..
......... yrs.
............ mos.
....
ds ..
Where was disease contracted, If not at place of death ? Former or usual residence. ....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
FGalungo Center
query
1916
........
20 UNDERTAKER
ADDRESS
3 24 Maisit's
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
1 PLACE OF DEATH 2 FULL NAME [If married or divorced woman or widow give maiden name, also nay,e of husband.] @RESIDENCE 3 SEX 4 COLOR OR RACE Male Juts · DATE OF BIRTH abul (Month) (Day) AGE .... & OCCUPATION (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 PARENTS Queland 18 BIRTHPLACE OF MOTHER (State or country) (Informant) CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very yrs. .mos. ds.
Cheles ford
Still Bow Graham
4 hour
If Chelwex ford Das
Registered No. 25
MEDICAL CERTIFICATE OF DEATH
(Month)
17
1916
(Day)
(Year)
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. - 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 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". (mercly 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, ctc.
R. 15-8-'15. 100,000.
-
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) - - Granada
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
Gerade
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16
File aps. 19, 1916 Edward & Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Parate.
4 COLOR OR RACE
1.1
5 SINGLE,
MARRIED,
WIDOWED.
OR/DIVORCED
(Write the word)
· DATE OF BIRTH
(Month)
(Day)
19/ (Year)
7 AGE
If LESS than
I day ......... hrs.
6
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).
9 BIRTHPLACE
(State or country)
00
(Duration)
yrs.
mos.
6
ds.
Contributory.
(SECONDARY)
... (Duration)
) ...
.......
... yrs.
..........
mos. de.
(Signed)
7 EVarney
M.D.
april 19, 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
DATE OF BURIAL
X
191.2.
20 UNDERTAKER
ADDRESS
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
.
182 Chel 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
1
V
Registered No. 26
16 DATE OF DEATH
april
...
V (Month)
(Day) 180
..... 1
1916
..........
(Year)
....
HEREBY CERTIFY that I attended deceased from
Straat 17. 1914, to.
af
fut 18 , 1916
6
that I last saw her alive on
april 18 , 196
and that death occurred, on the date stated above, at 40 m.
The CAUSE OF DEATH* was as follows :
Brosche, pneumonia
--
................
17
...........
...
PERSONAL AND STATISTICAL PARTICULARS
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Ward)
Hench Chilirose
...........
....
10 NAME OF
FATHER
Aceite Stisette
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 lineis 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 oecu- 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: Ccrebro-spinal fever (the only definite synonym is "Epidemie 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, peritoneum, ctc., Carcinoma, Sar- coma, etc., of .......... .... .(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ctc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report more 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, Suicidc, 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.
2
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
important. See instructions on back of certificate.
PARENTS
12 MAIDEN NAME OF MOTHER- Mary a. Richardson
13 BIRTHPLACE
OF MOTHER
(State or country)
Boston
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mirst. Rosamond Spaulding
(Address)
15 Filed. apr. 25, 1916 Edward & Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
april
(Month)
(Day)
1910 (Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
biseuse of the theory
(valvular)
(Duretion)
... yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration)
.yrs.
.mos.
ds.
20. there's
M.D.
(Signed)
afait 5. 1916 (Address)
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATII, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
.yrs.
mos.
In the
ds.
State
... yrs.
.mos.
ds ..
Where was disease contracted, If not at place of death ?. .............. Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Hart Pord Cem. So Chein ape 27 1916
20 UNDERTAKER Watter Pechan
183 Chelesfeed
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Over 1. Shoulding
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.1 @RESIDENCE Robin Hill Rd. To Chelmsford
Registered No.
27
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
m
4 COLOR OR RACE
While
D SINGLE
MARRIED,
WIDOWED,
OR DIVORCEDdower
( Write the Word
6 DATE OF BIRTH July
(Month)
15 1850
(Day)
(Year)
7 AGE
If LESS than 1 day, ........ hrs.
65
9
mos.
10
ds.
or ........ min. ?
yrs.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Carpenter
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
chelmaturo.
...
10 NAME OF
FATHER
Isiah B Spaulding
11 BIRTHPLACE OF FATHER (State or country)
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford (No Robin Hill Road
St. Ward)
....
25
ADDRESS
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.
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