USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 48
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...
.yrs.
3
mos.
at from
Scobona
... .
mans
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 usc of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber .
culosis of lungs, meninges, peritonaeum, etc., 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 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.
A
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
1 PLACE OF DEATH Clubmsford 2 FULL NAME [If married or divorced woman er widow give maiden name, also name of husband.{ @RESIDENCE Chelousford 3 SEX 7 7 4 COLOR OR RACE White · DATE OF BIRTH Sept ....... 7 AGE OCCUPATION (a) Trade, profession, or particular kind of work at home (b) General nature of industry. business, or establishment In which employed (or employer) .... 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 ......... ................... yrs. . .......... mos. ...
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No Chelmsford St
St. :
.Ward)
(City or town.) fif death occurred in a hospital or institution, give its NAME instead of street and number.]
Mary Elizabeth Hood
Mary E Campbell, James WHord.
Registered No. 32
PERSONAL AND STATISTICAL PARTICULARS
SINGLE,
MARRIED
WIDOWED,
rite the forth)
21 1839
/
(Month)
(Day)
(Year)
If LESS than day ......... hrs ..
or ......... min. ?
9 BIRTHPLACE
(State or country)
Nro. chelmsford
10 NAME OF
FATHER
John Campbell
11 BIRTHPLACE
OF FATHER
(State or country)
Londonderry N.++.
12 MAIDEN NAME
OF MOTHER
Nancy Emerson.
Ware. N. ++
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mrs. L.J. Parkhurst (Laughter)
(Address) Clicenstund. Mais.
16 May 10, 1916 Edward & Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH May 9
(Month)
(Day)
191 6 (Year)
17
I HEREBY CERTIFY that I attended deceased from
196
to
may
8
196.
......
1916
that I last saw he alive on.
mag
......
and that death occurred, on the date stated above, at 34 m.
The CAUSE OF DEATH* was as follows :
Carcinoma
of Liver
3
(Duration)
.. yrs.
........
ds.
Contributory.
(SECONDARY)
Duration)
................ yrs. ................ mos.
................ ds.
(Signed)
Arthur J. Scolonia
M.D.
Thay 9, 1916
(Address).
Chilis Body Pilares
* 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 ............ y ... ........... mos.
............ ...............
Where was disease contracted, If not at place of death ?..
Former or usual residence ..
PLACE OF BURIAL OR REMOVAL Riverside cem.
DATE OF BURIAL
No. Chelmsford. mario May 11
...
1916
20 UNDERTAKER
ADDRESS
Walter Perham Chelenstand.
188
........
.............
....
76
7
18
.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- 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 home, and children, not gain- fully employcd, 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 (rctired, 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 discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidciuic cercbro-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 usc 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 septicemia," "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.
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 4 Cimberet Struts.
. ................. ...... Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the wordy ()
DATE OF BIRTH
Mari 24 1916
(Month)
(Year)
If LESS than
[ day .......... hrs.
or ......... min. ?
9 BIRTHPLACE
(State or country)
forth Chelmsford
10 NAME OF
FATHER
William Mu laum
12 MAIDEN NAME
OF MOTHER
Anis moss
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Willian In Jam, father
(Address) Bolt Chefinsind
16 June 5, 1916 Edward & Fattura
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
May 24, 1916 to Jar 4/
1916
that I last saw h.
alive on
1916
... ,
and that death occurred, on the date stated above, at 3 30 am
The CAUSE OF DEATH* was as follows :
Tumbas Spina Bifida
(Duration)
yrs.
mos.
11
ds.
Contributory ... (SECONDARY)
(Duration).
.. yrs.
mos.
.dr.
(Signed)
...
fund Ellamey
..........
M.D.
Are 4 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).
At place
of death
.... yrs.
mos.
ds.
State ....
........... yrs.
In the
mos.
ds ..
Where was disease contracted, if not at place of death 7.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL Juni 196
20 UNDERTAKER
ADDRESS
1.1891
.........
(City or town.)
William
Bilans
Registered No. 33
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
forma
4
1916
(Month)
(Day)
(Year)
1 PLACE OF DEATH
220 Chelmsford
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
3 SEX
4 COLOR OR RACE
(Day)
7 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
(State or conntry)
England
PARENTS
18 BIRTHPLACE
OF MOTHER
(State or country)
England
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
............... YTS.
mos. .....
11
... ds.
MARGIN RESERVED FOR BINDING
-
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 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 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 "Laborcr," "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" (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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford
(NO ..........................
Bartlett
190 Chelmsford
(GHty ordown.)
Tlf death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME Ann Er Hartehorn.
[If married or divorced woman or widow Registered No. give maiden name, also name of husoand.] Ana- E, Barker Edward Hartahorn @RESIDENCE Chelmsford benter.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July 1,
(Month)
(Day)
1916 (Year)
$ DATE OF BIRTH
June
20 1841.
0
(Month)
(Day)
(Year)
If LESS than I day ......... hrs.
........ yrs.
75 /s. V mos.
11 ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
At Home
At Home
9 BIRTHPLACE
(State or country)
Lowell, Mass
10 NAME OF
FATHER
Alfred Di Barker,
11 BIRTHPLACE
OF FATHER
(State or country)
Mass
12 MAIDEN NAME
OF MOTHER
Eliza As young,
18 BIRTHPLACE
OF MOTHER
(State or country)
Marnes
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mare. Am B. Northruch.
(Address) Chelmsford Centers Mees,
16 July 4, 1916 Edward J. Rolling
REGISTRAR ....
17
1 HEREBY CERTIFY that I attended deceased from
1916, to Mels ·1
1916
......
that I last saw her alive on.
..............
1916
and that death occurred, on the date stated above, at/1, Lagam.
The CAUSE OF DEATH* was as follows :
Sarcoma of breast
(Duration)
29
mos.
de.
...
Contributory ..
(SECONDARY)
.(Duration)
.. yrs.
.mos.
ds.
(Signed)
M.D.
...
July 2 1916 (Addres 05 WEstrand St.
* 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 ..
.mos.
ds ......
.yrs.
....
Where was disease contracted, If not at place of death ?..
Former or
usual residence ...
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Lowell Cemetery, July 5, 1916.
20 UNDERTAKER
ADDRESS
BramaLealuz 79 Branch St.
1916 1841 75
-
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
MARGIN RESERVED FOR BINDING
.... ...... 7 AGE particular kind of work (b) General nature of industry, business, or establishment In 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 which employed (or employer) ...
3 SEX
Female, White
4 COLOR OR RACE
6 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Widowed.
St. ;.
Ward)
0
...
........... .......
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 "eases, 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- keepcrs 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 eausation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic eerebro-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, peritonacum, etc., Carcinoma, Sar- coma, etc., oî. .(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," "Dcbility" ("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 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.
191
Celebresfind.
.........
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Charles Frederick Sproule
2 FULL NAME. { If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Cheliusfind- Mars.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
m.
4 COLOR OR RACE
While
6 SINGLER
MARRIED
WIDOWED.
OR DIVORCEDwreed
(Write the word)
$ DATE OF BIRTH
november 17
(Month)
(Day)
18.71
(Year)
7 AGE
If LESS than
[ day ......... hrs.
44
yrs. 7 mos. 22 ds.
or ......... min. ?
* OCCUPATION
(a) Trade, profession, or
particular kind of work.
Butcher
(b) General nature of industry,
business, or establishment In
which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Exact Boston, Mark
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Leeland
12 MAIDEN NAME
OF MOTHER
Elizabeth Foster
18 BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mis C.F Sproule
(Address)
Chelmsford, mass.
1% Filed July 10, 1916 Edward Robbing ...... ....... REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July Hand 4
(Month)
(Day) )
** , 1916.
(Year)
17
I HEREBY CERTIFY that Iattended deceased from
1915
Cpr. 8
....... .
touw, to.
1916
-
that I last saw h Am alive on
. 1916
and that death occurred, on the date stated above, at 2 a. m.
The CAUSE OF DEATH* was as follows
Carcinoma of giver
(Duration)
..............
... yrs.
mos.
ds.
10 NAME OF
FATHER
Charles Steroule
Contributory ...
(SECONDARY)
(Duration) yrs
.mos. .............
.ds.
M.D.
...............
July 10, 1916 (Addres).
Chaleco ford, mais.
* 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).
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