USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 53
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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 strcct, 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
Migli
St. :
Ward)
......
(City/or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
51
PERSONAL AND STATISTICAL PARTICULARS
21 1850
(Month)
(Day)
(Year)
If LESS than ( day ......... hrs.
or ......... min. ?
10 NAME OF
FATHER
Jeremiah C. Mansfield
11 BIRTHPLACE OF FATHER (State or country) Chelmsford .
12 MAIDEN NAME
OF MOTHER
Susan E. Tacklenet
Chelmsford
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mis. G. P. Mansfield wife
Filed_ Oct. 10, 1916 Edward & Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
art.
(Month)
(Day)
8
1916
(Year)
17 I HEREBY CERTIFY that I attended deceased from Seht. 27 1916, to. 2,
oct. 8
1916
.
that I last saw him alive on.
oct. 8
......
196
and that death occurred, on the date stated above, at 11 a.m.
The CAUSE OF DEATH* was as follows :
Sarcoma of the colon.
/
(Duration)
... yrs.
... mos.
........ ds.
Contributory ...
(SECONDARY)
.. (Duration)
............. yrs. ............... mos.
. ............... ds.
(Signed)
masastoward
M.D.
Oct 10. 191.
1916 (Address) Chelmsford dias
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITAL'S, 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 Hart Ford Com. So, Chelmsford
DATE OF BURIAL
Oct. 10
6
191
20 UNDERTAKER
Walter Perkam Cheliusford
ADDRESS
PLACE OF DEATH Chelmsford .(No. Gear 2 FULL NAME car 8 SEX ‘ COLOR OR RACE M. 5 SINGLE, VARDIED ANDOWED ( Write the word) ' DATE OF BIRTH 7 AGE 66 3 & OCCUPATION farmer (a) Trade, profession, or particular kind of work ... (b) General nature of industry, business, or establishment In which employed (qr employer) ............ 9 BIRTHPLACE (State or country} Chehusford PARENTS 1ª BIRTHPLACE OF MOTHER (State or country) Cluelessfind important. See instructions on back of certificate. (Address) 15 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 ............. ...... mos. 15. ds.
2070 Chelenford
chers Mansfield
Lit married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE (helinstand.
....
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 Housc- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (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 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); 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 discase; 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 supposcd 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.
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
220 Chelmsford
(No
Mansur
....
St. :.....
Ward)
....
(City or town.) [If death occurred in .a hospital or institution, give its NAME instead of street and number.]
William J. Picken hr.
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
No. 6 helmeford.
0
Registered No.
52
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
* SEX
Maler
4 COLOR OR RACE
White.
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Single.
· DATE OF BIRTH
(Month)
(Day)
13, 19.16. (Year)
7 AGE Still Born.
.mos.
„ds.
Or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work ...
......
None.
(b) General nature of Industry,
business, or establishment in
which employed (or employer) .....
None.
9 BIRTHPLACE
(State or country)
No. Chelmsford, Masa.
PARENTS
12 MAIDEN NAME
OF MOTHER
Nellie R. Redman
1ª BIRTHPLACE
OF MOTHER
(State or country)
Chelmsford, Mass.
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ...
Am. V, Picken.
(Address) No, 8 helmsfords Mass.
16
Filed Oct 14, 1916 Edward to Rafting
....
REGISTRAR
18 DATE OF DEATH
Oct.
13.
(Month)
(Day)
....
1916
(Year)
17 I HEREBY CERTIFY that attended deceased from
191
Del-13
1916
to
191
.... , ....... · and that death occurred, on the date stated above, at 11,45 P. P.m. The CAUSE OF DEATH* was as follows :
............ Shell barn
(Duration) .
... yrs.
mos. ds.
Contributory. (SECONDARY)
........ (Duration)
.yrs.
mos.
.. ds.
(Signed)
7 Evanes,
M.D.
Q4.14
,1916
......
* 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.
.. mos.
OS ...
State ..
............ yrs.
Where was disease contracted, If not at place of death ?.
........................................................................................ Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Edson Cemetery.
DATE OF BURIAL
Ock
191 6
...................
20 UNDERTAKER
Gromareales.
ADDRESS
19 Branch Sta
......
........ ...... ....
10 NAME OF
FATHER
Am. J. Picken
11 BIRTHPLACE
OF FATHER
(State or country)
bonn
.........
--
If LESS than
1 day .........
...... his.
that I last saw h.
alive on /
........................................
208 No. 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 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 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," 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 ncoplasms) ; 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: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mcre 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.
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 Butterfield tuves
1 PLACE OF DEATH Chelmsford (No. on Inten Rd St.
Edward Oftorne
2 FULL NAME
{If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Registered No. 33
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male,
4 COLOR OR RACE
White.
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Widowed.
6 DATE OF BIRTH
· (Monthi)
(Day)
7 AGE
If LESS than I day, ......... hrs.
60
.... yrs.
mos.
.ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Chef.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
Chef
he
9 BIRTHPLACE
(State or country)
Lebanon, Me.
Contributory
(SECONDARY)
.(Duration) 1.0.1hours
M.D.
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, 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.
ds.
State.
... yrs.
mos.
ds ..
Where was disease contracted, If not at place of death ?.
Former or usual residence
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Karl & Horne
(Address)
Jerry, N. 71
15
Filed Dec. 4, 1916 Edward S. Kobling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
1916
(Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
Exposure
.(Duration) .
yrs.
.mos. ds.
10 NAME OF
FATHER
Henry H. Horne.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Me.
12 MAIDEN NAME
OF MOTHER
Unknown.
18 BIRTHPLACE
OF MOTHER
(State or country)
Unknown,
1
---
Ward)
209 Chelifing (City-or-town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
19 PLACE OF BURIAL OR REMOVAL DATE OF BURIAL Jestlawn Cemetery Decin 4, 1916
20 UNDERTAKER Gro Matealey
ADDRESS
79 Branch R.
4
5 1856, .... (Year)
17
mos. ds.
(Signed)
fre 1, 196 (Address)
(Addres 1611 Themback/
In the
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- molivc 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," ctc., without more precise specification, as Day laborer, Farm laborcr, 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 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 (ncver 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 necd not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mcre 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," "Uracmia," "Weakness," etc., when a definite discase 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- posurc, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R 16. 3.'16. 5,000.
(54
Name, .... Janet. Walker ..
210
Place of death, .. . Manchester .. . N ... . H ..... No. .. 1038 ... Union .. Street.
Ward, . Village, ·
Residence W. Chelmsford Mass. How long a resident,. . . . 40 years.
Previous residence, .... Laconia .. . . N .. . ... ... If death occurred at an institution give name of same
How long an inmate, ..
Where from, Date of death: Year, 1.9.16Month,.Now. Day, ... ]. ..
Age:
Years,. . 82. . .. Months, .... ... Days,.
Place of birth, ...... Scotland ..
Date of birth: Year, 1834Month, .Aug. Day,. ....
Married, Single, )
Sex, ... .. . Color,. .......
Widowed or
.s.
Divorced.
Occupation,
Cause of death, ....
çidental . illuminat-
asphyxiation
ing gas
Duration,
Brief .......
Contributing cause,
...
01dage
Duration,
Name of father, ... James Walker ..
Maiden name of mother, .... Jean Hogg.
Birthplace of father, ...... Scotland ...
Birthplace of mother, ..
Occupation of father, ..
[Record continued over. ]
Deceased was wife of.
Widow of
Name of physician (or other person) reporting said death, . Maurice . Watson, Hed.Ref .. P. O. Address, .... Manchester. ........ H .... Place of interment,. Chelmsford, Mass. Date of interment, .... November .. 4 ,.1916. Name of cemetery, ... W .. Chelmsford. Undertaker, .Elmer.D ... Goodwin.
P. O. Address,. . ...... . Manchester., N.H.
THE STATE OF NEW HAMPSHIRE
I hereby certify that the above death record is correet to the best of my knowledge and belief.
Clerk of Manchester N.H.
Date, ..
November .. 13 ... 1916
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
(City or town.)
Loth Chelios Ford
.(No.
mt. Pleasant
St. :
.......
.Ward)
{If death occurred in
a hospital or institution,
give its NAME instead
of street and number.]
Margaret &
Icollan
2 FULL NAME
[If married or divorced woman or widow
Margaret & Shawle Owen callan,
give maiden name, also name of husband.]
@RESIDENCE
Registered No.
55
Mt Pleasant St. Inth Cheliv And
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
1
5 SINGLE,
MARRIED,
WIDOWED,
16 DATE OF DEATH
mailed
11
(Day)
(Month)
3
OR DIVORCED
(Write the word)
(Year)
· DATE OF BIRTH
I
17
-..
(Month)
(Day)
(Year)
1 HEREBY CERTIFY that I attended deceased from
May 1, 1916, to
Nov 3, 1916.
7 AGE
...
that I last saw her alive on.
Nov 2, 1916.
and that death occurred, on the date stated above, at 4Gr
Or ......... min. ?
m.
The CAUSE OF DEATH* was as follows :
If LESS than
1 day ........ hrs.
.......
.... yrs.
mos.
ds.
8 OCCUPATION
at tous
(a) Trade, profession, or
particular kind of work
Carcinoma of Breast
(b) General nature of Industry,
business, or establishment In
11
which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Contributory
......
General Debelle
....
10 NAME OF
FATHER
Michael Phunley
(SECONDARY)
Ireland
mos.
ds.
(Duration) ..
2
..... (Duration)
nunley
6!
Lyrs.
.... mos.
............... ds.
(Signed)
....
M.D.
=
11 BIRTHPLACE
......
Urefand
....... ,
OF FATHER
(State or country)
. 1919
(Address)
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
12 MAIDEN NAME
In the
OF MOTHER
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
PARENTS
At place
Jefard
of death
.yrs.
............ mos.
... ds.
State ....
mos.
ds.
... yrs.
Mary Sill
13 BIRTHPLACE
OF MOTHER
(State or country)
Where was disease contracted,
If not at place of death ?..
...
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
usual residence
Former or
(Informant)
Own callan rusland
19 PLACE OF BURIAL OR REMOVAL
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
DATE OF BURIAL
(Address) Ty GGlescan't VS
I Patika Cemetery,
important. See instructions on back of certificate.
....
.......
1916
20 UNDERTAKER /
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
.............
ADDRESS
15 File 200 5 96 Edward , Rolling
REGISTRAR
211, Chelmsford /200
1916
....
-
-
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 fircman, 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," "Forcman," "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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