USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 47
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Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, 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," "Scnile," 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. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."
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, ete.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 16-8-'15. 5,000.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
& SEX Filmale $ DATE OF BIRTH .... 7 AGE yrs. (b) General nature of Industry, business, or establishment in 11 BIRTHPLACE OF FATHER (State or country) PARENTS 13 BIRTHPLACE OF MOTHER. (State or country) 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 which employed (or employer) ............
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Hast Chelmsford (No West chelmsford Road.
184 Chelmsford
(City or town.)
Tlf 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.1 @RESIDENCE
West Chelmsford Road Ly Registered Nr. 28
PERSONAL AND STATISTICAL PARTICULARS
+ COLOR OR RACE
white
6 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
suple
Jan 29 1916. (Month)
(Day)
(Year)
If LESS than
[ day ......... hrs.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work ......
.................
none
9 BIRTHPLACE
(State or country)
Lourd
10 NAME OF
FATHER
Michael Liebedzinski
12 MAIDEN NAME
OF MOTHER
Many Salona
Russia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Michael Liededzinski
(Address) West Chuelund Road
16 File apr. 27, 1916 Edward & Rotting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
april
(Month)
(Day)
1916. (Year)
17 I HEREBY CERTIFY that I attended deceased from
191.
to
about 26
1916
that I last saw her
alive on
april 26 :
196
and that death occurred, on the date stated above, at 5 a.m.
The CAUSE OF DEATH* was as follows :
... (5
................ yrs.
Ros.
„ds.
catered medical examiner + he says
Contributory ........
... (SECONDARY) OUWEFF.
(Puration) .............. yrs. ................ mos. ................ as.
(Signed)
JEVarney
M.D.
Cfr 27. 1916 (Address)
............ ....... " 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).
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 Arpatucks Lowell aquel 28 191 6
20 UNDERTAKER
ADDRESS 176 Gorham 85
St. :
Ward)
Tranas
Liebedzinski
Ford
27
......
Came suddenly art lived
....
3
mos.
ds.
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- molive 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 necded. 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 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 ncoplasms); 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- acmia" (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.
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 Dalton Road
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
gris Andrews
2 FULL NAME
{If married or divorced woman or widow give maiden name, also pame of husband. @RESIDENCE Chelmsford
Lois Wilkins, Luther M. andrews.
29
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 7 1
4 COLOR OR RACE
& SINGLE
MARRIED,
WIDOWED./
widowed
(Wrue the word)
5 1837
0 (Months
(Day)
(Year)
7 AGE
79.
3
. 28
.... mos.
ds.
of ......... 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)
Waterford me.
........
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Waterford, Me.
12 MAIDEN NAME
OF MOTHER
Lorena Lovejoy
13 BIRTHPLACE
OF MOTHER
(State or country)
Norway, Ime
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
J. Mums andrews
(Informant)
(Address) Lowell- Mass
16 may 4, 1916 Edward). Robbing Filed. ...........
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
man
1916
...... (Month)
(Day) ..... .
(Year)
17
HEREBY CERTIFY that I attended deceased from
for the paraf plan
191.
to
191
.........
May
that I last saw has alive on.
........
1916
and that death occurred, on the date stated above, at/ 9m.
The CAUSE OF DEATH* was as follows :
......
prinquestion. She when suzed will
Pneumonia May 27 ch 1916
.....
.( Duration ) .
... yrs.
ds.
Contributory .....................
............................................................................................
(SECONDARY)
.. (Dușation).
.......
... yrs.
.mos.
ds.
(Signed)
SGMJanno
M.D.
May #4 10
1916 (Addres) ..
............
....
226 HarnackSI
.....
* 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 ..
... yr$. ............ mos. .
........
In the
ds.
State ....
....... yrs.
.... mos ..
. ............ .................
Where was disease contracted, If not at place of death ?..
Former or usual residence .....
19 PLACE OF. BURIAL OR REMOVAL
Lowell Cemetery
DATE OF BURIAL
May 5
191
6
* UNDERTAKER Walter Tenham
ADDRESS
Chelmsford
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
10 NAME OF
FATHER
William K. Wilkins
If LESS than i day ......... hrs.
...... yrs .. athous
......
...
.........
' DATE OF BIRTH, January
18.5 Chelmsford
......
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 engincer, 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," ete., 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 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 domestie 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 oceu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fevcr (the only definite synonym is "Epidemie 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, 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,". "Shoek," "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 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 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, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Boscawen N.H
12 MAIDEN NAME
OF MOTHER
Eliza a. Marshall
18 BIRTHPLACE
OF MOTHER
(State or country)
Chelmsford Mass.
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. R. W. Llix
(Address)
East Chelmsford. Mars
16 File may 6 , 1916 Edward Rotting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
may
5
(Month)
(Day)
1916
(Year)
* DATE OF BIRTH
aug.
27 VIST4
1
(Month)
(Day)
(Year)
7 AGE
71 ys. 9
mos .. ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work.
at Home
The CAUSE OF DEATH* was as follows :
Myocarding Digeneration
..............................
.. (Duration)
2 yrs. +
...................
Contributory
(SECONDARY)
......... (Duration).
/ ................ yrs.
.............
.mos.
(Signed)
......
Arthur / Scoorria
....
M.D.
May 6,, 1916, (Address) Chilimotorrad Mary.
.......
* 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.
Stato ............ y ... ............ mos.
.........
ds .............
Where was disease contracted, If not at place of death ?.
Former or
................. .......... usual residence ... C .........
19 BLACE OF BURIAL OR REMOVAL Houfather
DATE OF BURIAL
May'7
191
......
6
20 UNDERTAKER
Walter Tenham
ADDRESS
Chelmsford
...
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Mary ann Eliza Marchall
' FULL NAME.
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Carlisle, mass.
1.86
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
East Chelmsford
(No
learticle SX
............
St. ;...................... ... Ward)
....
Registered No.
30
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED
(Write the word)
....
17 I HEREBY CERTIFY that I attended deceased from
.. .
191 ........
to
May. 4. 1916
..................
191 that I last saw h ............ alive on ....... ......... and that death occurred, on the date stated above, at ..................... m.
........
If LESS than
I day ........ hrs.
....... f.
........... yra ..
.......
(b) General nature of industry, business, or establishment In which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Chelmsford
..........
10 NAME OF
FATHER
George Marshall
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
....
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. g .. Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ctc. Women at home, who are engaged in the duties of the houschold 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 diseasc. 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," 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 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
STANDARD CERTIFICATE OF DEATH
(No
North Street
Ethel Thurston
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE cheelmsford
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
W BOWED
Write fried
28 1883
(Month)
(Day)
(Year)
If LESS than I day, ........ hrs.
9
ds.
or ......... min. ?
9 BIRTHPLACE
(State or country)
Lowell- Mars
10 NAME OF
FATHER,
Henry 4. Sturtevant
(State or country)
Dunstable Mais
12 MAIDEN NAME
OF MOTHER
Ada Harper
Canada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Walter Houston
Filed ed may 8, 1916 Edward & Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH may 1
(Month)
(Day)
191.
(Year)
17
1 HEREBY CERTIFY that I attended deceased from
1916 to
'
May 7 96
that I last saw h .. cK. alive on ...
May 6, 196
and that death occurred, on the date stated above, at.
.m.
The CAUSE OF DEATH* was as follows :
Pulmonary Intercalary
...
(Duration)
.. yrs.
mos. ds.
Contributory .. (SECONDARY)
Arthur
.........
Duration)
... yrs. .........
C.mos.
ds.
(Signed)
....
M.D.
May 8, 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 ?. ... usual residence ... Former or
19 PLACE OF BURIAL OR REMOVAL Wertlawn Um.
DATE OF BURIAL
May 9
1916
towels mars.
20 UNDERTAKER
Walter Pecham
ADDRESS
........
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Echel Sturtevant, Walter 7. Thurston
187 Chelmsford
St. ;... Ward)
Registered No. 31
€ ..........
1 PLACE OF DEATH
2 FULL NAME
3 SEX
4 COLOR OR RACE
w
" DATE OF BIRTH
Can
AGE
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
11 BIRTHPLACE
OF FATHER
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
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
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
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