USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 49
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At place
of death
....... yrs.
In the
.......
.... mos. .......
... ds.
State ............ yrs.
...
.mos.
.................
Where was disease contracted, If not at place of death ?.
Former or usual residence. .......... ........
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL Pine Ridge Chelmsford July 11
1916
20 UNDERTAKER
ADDRESS
Waller erkan Chickensfund.
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
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelinsford Mask (No. Dalton Road
.......................
St. ;........................ Ward)
.........
...... ...... ...
(S)gned)
Auchin /, colonia
....
.......
......
Registered No. 35
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 cxamples: (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," "Dealcr," 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 houschold only (not paid Housc- keepers who receive a definito salary), may be entered as Housewife, Houscwork, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation 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 discasc. 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," 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" (mcrely 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 scpticaemia," "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- posurc, 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 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
Hast Chelmsford (No Carlton a ava
St. :..
Ward)
E. Chelmsf. (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Still born Darby
[If married or divorced woman or widow
give maiden name, also name of husoand.1
@RESIDENCE
Carlton ave wast Chelmsford
.
Registered No. 36
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
· July 12th
191 ..... 6.
(Month)
(Day)
(Year)
* DATE OF BIRTH
July 11th
........
2 .......
(Month)
(Day)
- (Year)
7 AGE
If LESS than
t day ......... hrs.
or 0 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)
East Chelmsford
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Towell wass
12 MAIDEN NAME
OF MOTHER
Katie Roberts
18 BIRTHPLACE
OF MOTHER
(State or country)
H
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Father
(Address) Carlton ave E. chelmsford
16 July 15, 1916 Edward to Robbins
Filed ...
6.
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
191
to
tuy 11
..........
1916
that I last saw h ..
alive on.
191.
....... 1
and that death occurred, on the date stated above, at.
.m.
The CAUSE OF DEATH* was as follows :
(Duration)
... yrs.
mos.
ds.
Contributory .. (SECONDARY)
.) ...... (Duration) ...
g .. yrs. ......
.mos.
ds.
15. 4-011' Charte
M.D.
Dich, 13.19/16
(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 ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Edson Cemetery July 14, 196
20 UNDERTAKER Young + Blake
C ADDRESS
Prescott. st
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
male
white
1
0 ........ yrs. ....... 0 ...... mos. .... 0 ds.
....................................................................
10 NAME OF
FATHER
Albert Harby
(Signed)
.......
...
....
MARGIN RESERVED FOR BINDING
192
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 thereforc 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 employcd, 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. - Namc, 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 ("Pncunionia," unqualified, is indefinite) ; Tubcr-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, ctc., of .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (sccondary), 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.
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
North Chelmsford (No. 7 Gay
St. ;................
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
Francis Powers
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
7 Gay St. North Chelmsford
Registered No.
37
PERSONAL AND STATISTICAL PARTICULARS
& SEX Male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED, TI
WIDOWER Married
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
25
... yrs. mos. ... ds.
Or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Tool-sorter
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE
(State or country)
North Chelmsford, Mass.
10 NAME OF
FATHER
----- Powers
PARENTS
12 MAIDEN NAME
OF MOTHER
Bridger Mungoven
18 BIRTHPLACE OF MOTHER (State or country)
North Chelmsford
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. Francis Powers
(Address)
7 Gay St. N. Chelmsford
16
Filed ang 5, 1916 Edward. Bobbing
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
...........
.. 1916, to
Guage 196
that I last saw his alive on Cuatro
191
and that death occurred, on the date stated above. 3/2
The CAUSE OF DEATH* was as follows :
1
Acute Lokan Iemmanca
(Duration) ..
.......
.... mos. ........ .... ds.
Contributory ...
(SECONDARY)
Juhunay quanstage
(Duration) ...
... yrs.
mos.
ds.
(Signed)
M.D.
...........
(Address)
Numquotas.
* If death followed injury or violence the certificate of death must be made out Vy/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.
Where was disease contracted, If not at place of death ?.
Former or usual residence. ..............
19 PLACE OF BURIAL OR REMOVAL St. Patrick (Lowell)
DATE OF BURIAL
Aug. 6 . 196
20 UNDERTAKER O'Connell & Mack
ADDRESS
658 Gorham St
...
(Month)
(Day)
1916
(Year)
....
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
193
North Chelmsford -
Margaret (Barry) Powers
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
aug zhe
If LESS than
I day ......... hrs.
............. m.
11 BIRTHPLACE OF FATHER (State or country) Ireland
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, pcritonaeum, 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) affeetion need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely 'symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility". ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage,". "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation,. Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15-8-'15. 100,000.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Stalnatural Light, (No
...
Halter Henry
tofun.
[If married or divorced woman or widow give maiden name, also name of husband.1 @RESIDENCE Brooklyn N. L. 10% Trois Are.
Registered No. 38
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Mala.
4 COLOR OR RACE
Irhilo
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
-
.........
(Month)
(Day)
AGE
If LESS than
[ day ......... hrs.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
To Posion Mask.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Lowvill Hace.
12 MAIDEN NAME
OF MOTHER
Ida, M. Rofor.
da
18 BIRTHPLACE
OF MOTHER
(State or country)
Stoughton Mass.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Stallen C. Cobram
(Address) 103 Lavie An Brooklyn MIT.
15 File Ong 14,, 1916 Gerard Y. Bobbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
lugnat
12
.....
1916 ......
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
(Year)
aug 10
.....
191_
dead
.......
....... , to.
191
that I last saw ha alive on.
1916
and that death occurred, on the date stated above, at 8 am.
The CAUSE OF DEATH* was as follows :
Chronic valvular heart disease .....
.....
(3+)
(Duration) ...
yrs.
.mos.
ds.
Contributory .......
acute dilatation
(SECONDARY)
(Duration)
mos.
............. yrs.
3 ds.
(Signed)
M.h. vAllein.
M.D.
lowa 14, 1916 (Address).
14.
ss) torkel has
.
* 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.
mos.
ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence .. .....
19 PLACE OF BURIAL OR REMOVAL
Edson Sameby
DATE OF BURIAL
Cup15 1916
......................
20 UNDERTAKER
1
ADDRESS
96 Branch She
194
(City or town.)
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
important. See instructions on back of certificate.
In the
..
10 NAME OF
FATHER
14
. 8 mos. 12 ds.
.. mos. ...
....... yrs. ...........
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulncss 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 cxamples: (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 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 dcad, etc.
MARGIN RESERVED FOR BINDING
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
18 BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Celiusfind Mass
Filed ... aug 18, 1916 Edward . Robban P ... · REGISTRAR ....
0
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford) ....................... (No.
.... Second
.....
.St. ;.
Ward)
(City of town.) Elf death occurred in a hospital or institution, give its NAME instead of streat and number.]
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