USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 54
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Statement of cause of death. - Name, first, the DIS- DASE 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 (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report more symptoms or terminal conditions, such as "Asthenia,". "An- aemia" (merely symptomatic), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital,". "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage,", "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all Aiseascs 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.
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
Golden Cora.
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
Orion A, Brook's Charles H. Manahow,
Registered No.
56
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
1 5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
63
mos. ds.
or ......... min. ?
-
-
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Taylor V. M.
PARENTS
12 MAIDEN NAME
OF MOTHER
Anhangh I right.
18 BIRTHPLACE OF MOTHER (State or country)
Herford Mask.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Flora, de Survivalou
(Address)
15
Filed. Dru. 12. 1916 Geraid . Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Nor.
(Month)
(Day)
1916- (Year)
17
I HEREBY CERTIFY that I attended deceased from
1914
to
nov. 9, 196
..........
that I last saw het alive on nov 9, 1916 ... and that death occurred, on the date stated above, at ... ................... m.
The GAUSE OF DEATH* was as follows :
General Ultimo- scherven
(Duration).
3. ... or work
.mos.
.. ds.
Contributory ..
(SECONDARY)
(Duration)
....... yrs. .........
....... mos.
„ds.
(Signed)
Anten C. Scolonia,
...
Clubes ful man.
M.D. f
7200 10 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 ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Escon formation
DATE OF BURIAL
Nov, 12th, 19162
20 UNDERTAKER Simmons HBrown
ADDRESS
96 Branches
212
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. ;..
................. .. Ward)
... ,
...
A Monahan
...
10
....
If LESS than
[ day .......... hrs.
........
& OCCUPATION
(a) Trade, profession, or
particular kind of work
10 NAME OF
FATHER
Starke Fr. Brooks
11 BIRTHPLACE
OF FATHER
(State or country)
n.y.
....
.........
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 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- DASE 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" (mercy 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 Aiseases resulting from childbirth or miscarriage, as "PUER- ١٠ 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.
1916- 79- 1837-
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)
Ne.
12 MAIDEN NAME
OF MOTHER
Sylvia & toner
1ª BIRTHPLACE
OF MOTHER
(State or country)
Macar
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mm. N. Kilbourne
(Address) Chelmsford Mace
15
Filed, Nov. 14. 1916 Edward J. Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Females
4 COLOR OR RACE
Arhite.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Nov.
12, 1916
(Month)
(Day)
(Year)
$ DATE OF BIRTH Jan 29 18(3) (Year)
0
(Month)
(Day)
If LESS than
1 day ......... hrs.
or ......... min .?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ...
At Home
....
(b) General nature of industry,
business, or establishment In
which employed (or employer) ....
At Home.
9 BIRTHPLACE
(State or country)
Waterford Men
.. (Duration) .
ds.
mos.
............. yrs.
-
Contributory.
(SECONDARY)
(Duration) 6 yrs. mos.
ds.
(Signed)
Antun , Scobona
......... , M.D.
2200.12. 1916 (Adress) Chileno ford, mans
* 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, CR RECENT RESIDENTS).
At place
of death
yrs.
mos.
ds.
State
yes.
mos.
ds ..
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Frefather's Cemetery,
DATE OF BURIAL
Chelmsford Kasas Nov, 14, 1916
20 UNDERTAKER
GromoJealeys
ADDRESS
79 Branch &K.
2/3 Chelamalarda (Gity or town.)
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
(No.
Littleton Road,
.St .;
... Ward)
[If death occurred in a hospital or institution, give its NAME ·nstead of street and number.]
Maria de Kilbourne
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford benter.
Maria Saunders, Mr Killour
Registered No. nes 5%
PERSONAL AND STATISTICAL PARTICULARS
The Commonwealth of Massachusetts
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
17 I HEREBY CERTIFY that I attended deceased from nov. 4 1916, to 2100 12 1916
that I last saw her alive on.
Nov, 12 1916
and that death occurred, on the date stated above, at 12.30
The CAUSE OF DEATH* was as follows:
-
Cante Lobar Incremona
10 NAME OF
FATHER
Amor Saunders
In the
....
? AGE
79 yrs. 9 mos. 14
„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 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- BASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of .. ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; 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 seases 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.
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.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 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
1 PLACE OF DEATH
East Chelmsford (No.
... Centre St
Ward)
(City or town.) fif death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
& SEX
finale
+ COLOR OR RACE
white
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH
Ater, 14th-
(Month)
(Day)
(Year)
7 AGE
If LESS than
! day .......... hrs.
.... mos. ds.
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)
forthe Mass,
10 NAME OF
FATHER
¿porquestur
tiffin Laughton
11 BIRTHPLACE
OF FATHER
(State or country)
lo Sowell Mass
12 MAIDEN NAME
OF MOTHER
Leurgiana Stelch
18 BIRTHPLACE
OF MOTHER
(State or country)
Unity Av. J.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Slikhan Sranghton
(Address)
16 Filed 202 14 1916 Ederard De Robbins ............
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
nov.
14
1916.
(Month)
(Day)
(Year)
19/6/
17
I HEREBY CERTIFY that I attended deceased from
nov.14
.......... ,
191, to
nor.14 196
that I last saw h _~~ alive on
.........
191
and that death occurred, on the date stated above, at ..................... m.
The CAUSE OF DEATH* was as follows :
Still ben
-
..... (Duration) ................ yrs. ................ mos.
ds.
............
Contributory .. (SECONDARY).
(Duration)
................ mos.
ds.
(Signed)
Antrin 4, EScaborca
M.D.
nov.15-
. 1916 (Address).
Clubes ford. man
* 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
191 €
20 UNDERTAKER
Yes. M. Eastman
ADDRESS
363 Bridge
214
Registered No.
58
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.1
@RESIDENCE
East Chilifoul
Still for Laughton
....
....
...
......
PARENTS
........
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 "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonaeum, etc .; Carcinoma, Sar- coma, etc., of .. ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection necd 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.
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 Th Chelmsford (No. Main St. W. Chelmsford St. :
2 FULL NAME
William Keenan
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Main St
West Chelmsford Mass.
....
59
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCEMarried
(Write the word)
6 DATE OF BIRTH
1853
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
I day .......... hrs.
63
... yrs.
mos. ...
ds.
Or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Farmer
(b) General nature of industry,
business, or establishment In
which employed (or employer) ...
Farmer
9 BIRTHPLACE
(State or country)
South America
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
California
12 MAIDEN NAME
OF MOTHER
Unknown
Timmer
13 BIRTHPLACE
OF MOTHER
(State or country)
Unknown
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs Bridget Keenan
(Address) Main St. W. Chelmsford
File 2100. 24, 1916 Edward J. Robbing ...... REGISTRAR
16 DATE OF DEATH
11
(Month)
21
... ,
191 4
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Nov 16, 1916, to.
Nov 21. 1916.
that I last saw him alive on.
Nov 18, 1916.
and that death occurred, on the date stated above, at / Cm.
The CAUSE OF DEATH* was as follows :
Mitral Reguigstation
...............
... (Duration) .
2
yrs.
... mos.
ds.
Contributory
arterial
...
(SECONDARY)
(Duration) 9
) ............... yrs.
.........
(Signed)
James
.......... , M.D.
, DOC (Address)
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
IS 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's Lowell
DATE OF BURIAL
Nov. 24
6
.....
191
20 UNDERTAKER
John L. MeDonough
ADDRESS
176 Gorham
Lowell
MARGIN RESERVED FOR BINDING
215
Chelmsford
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
(Day)
........
ds ...
.. mos.
.................
.. ds.
10 NAME OF
FATHER
Unknown Keenan
.........
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," "Dcaler," 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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