USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 55
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Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ..................... (name origin: "Cancer". is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy,". "Collapse," "Coma," "Convulsions,". "Debility", ("Congenital," "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, Suicidc, 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.
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
Pergia S. Libby
1ª BIR SHPLACE
OF MOTHER
(State or country)
Lowell
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
-- 1
(Address)
Chelmsford mais
16 2202. 30 1916 "Edward Y Retting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
...
(Month)
(Day)
(Year)
" DATE OF BIRTH
30
1916,
(Month)
(Day)
(Year)
7 AGE
·
If LESS than
I day./.2. hrs.
0
0 ..... mos. 0 .ds.
.... ...........
or V ......... 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)
Chelmsford
(Duration)
.yrs.
mos. ds.
..........
Contributory ..........******
........................
.........
(SECONDARY)
.(Duration)
... yra.
.mos.
...
ds.
(Signed)
26 86 Su
M.D. Dec 1 196 (Address) 5.2 Sur Realiz Lamell Mars ......
* 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. ............
Where was disease contracted, if not at place of death ?.
Former or usual residence. ....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Forefathers Cen.
....
1916
Filed
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford (No. 2
........
' FULL NAME
Dutton
[ If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford
Registered No.
60
PERSONAL AND STATISTICAL PARTICULARS
& SEX
Hemala
I COLOR OR RACE
white
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
...... .................................
216
Chelmsford
............... (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. ;..
Ward)
30 .1916
.....
17 I HEREBY CERTIFY that I attended deceased from 20 - 30 ...... .
1916, to Have 30
1916
that I last saw her alive on.
nov 30
1916
and that death occurred, on the date stated above, at 1. frm.
The CAUSE OF DEATH* was as follows :
Premature birth
12 horas
10 NAME OF
FATHER
Francis 6. Dutton
11 BIRTHPLACE
OF FATHER
(State or country)
Chelmsford
......
..........................................
.......... ....
Francis Q. Bution
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
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 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," "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.
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: Cercbro-spinal fcver (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, Suicidc, 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.
.... 3 SEX 3 AGE & OCCUPATION 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 ...
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH howelf mars 1 (No. howell Gew. Storp, St .; Ward)
217
Lowell
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
mary Wilkinson
[If married or divorced woman or widow
give maiden name, also name of husband .!
@RESIDENCE
no. Chelmsford Mass.
Registered No. 61 ....
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
Female White
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word Married
6 DATE OF BIRTH
October 30
18577
17
(Month)
(Day)
(Year)
If LESS than t day ......... hrs.
379
yra. m
-.. yrs.
mos .......
2,
......... ds.
or ......... min. ?
(a) Trade, profession, or
particular kind of work.
at Home
(b) General nature of industry, business, or establishment In which employed (or employer) ...
9 BIRTHPLACE (State or country) Belgium
10 NAME OF
FATHER
Ceoral Aracup
11 BIRTHPLACE
OF FATHER
(State or country)
England
12 MAIDEN NAME
OF MOTHER
martha-
1ª BIRTHPLACE
OF MOTHER
(State or country)
unknown
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Husband
(Address)
W. Chelmsford Mass,
16 Wep 4
REGISTRAR
16 DATE OF DEATH
December 3
(Month)
(Day)
1916 (Year)
I HEREBY CERTIFY that I attended deceased from november 20 1 916 to December 2016 that I last saw her alive on. 1916 and that death occurred, on the date stated above, at. 7. B. a.m. The CAUSE OF DEATH* was as follows : Sestio Troumoni ' auf following an operation for Inguinal Hernia
.........
.(Duration).
............. yrs.
.mos.
.. ds.
Contributory.
(SECONDARY)
(Duration)
Dyrs.
.......
...........
.. mos. . .............
ds.
Nee, 2
.,
(Address) LowellGen Hotep
* If death followed injury or violence the certificate of death must be malle 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 Riversidelem, Chelmsford Dice. 61916
DO UNDERTAKER Geo. W. Healey
mass !
ADDRESS 79Branchst.
...
(Signed)
Burtona Louereu
M.D.
.......
Mary Dracup-Samuel
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 cach 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, Architeet, 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) Groeery; (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 tlic 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 DEATHI (the primary affection with respect to tiinc and causation), using always the same accepted terin 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"); Lobur 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," "Senilc," 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 septicacmia," "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 discasc, as A death upon the street, or one supposed to be due to Alcoholism, ctc
4. Deaths under circumstances unknown, as A person found dead, etc.
R 18. 3-'16. 10,000.
4.
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 Chelmsford (No. Thatle Road
St. : ....... Ward)
218 Chelifed
.......
(City or town.) Tlf death occurred in a hospital or institution, give its NAME instead of street and number.]
Oramel H. Foster
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE maple Road So Chelmedard
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Inale
4 COLOR OR RACE
white
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH Nav 18-1550 (Month)
(Day)
1
(Year)
7 AGE
If LESS than [ day ......... hrs.
3
... yrs.
8 OCCUPATION (Retired
(a) Trade, profession, or particular kind of work.
(b) General nature of industry, business, or establishment in which employed tor employer).
9 BIRTHPLACE (State or country) Worcester Termour
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Vermont'
12 MAIDEN NAME OF MOTHER Non Renown
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
C.Zn. allen
(Address)
15 Filed Dec. 24/ 1916 Edward Robbins
REGISTRAR
...
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
Myecarditis (Chris)
(Duration)
.yrs.
mos. ds.
Contributory .. (SECONDARY)
(Duration) ........... yrs. .mos.
ds.
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, OF 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 usuaí residence.
19 PLACE OF BURIAL OR REMOVAL Edron Cemetry
DATE OF BURIAL Dec 24/1996
20 UNDERTAKER
ADDRESS
Youngand Blake
Registered No.
62
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
21
(Month)
(Day)
1916
(Year)
66
/
mos.
ds.
or ........ min. ?
-
1
MARGIN RESERVED FOR BINDING
10 NAME OF FATHER Hermon Garter
(Signed)
bre. 23
.. , 191 4 ..... (Address) ...
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, ete. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid 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 oceupations 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 cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
1
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shoek," "Uraemia," "Weakness,". etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, OF 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 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.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX male 7 AGE & OCCUPATION (a) Trade, profession, or particular kind of work. PARENTS 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 0
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford
............
(No.
Turnpike Road
St. ;..............
.Ward)
2 FULL NAME
Charles F. Sweeney
1lt married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chemont
Registered No.
63
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Due
23
(Month)
(Day)
1916,
(Year)
* DATE OF BIRTH Die 19 1916
(Month)
(Day) (Year)
If LESS than
1 day ......... hrs.
......... yrs.
.... mos.
4
.ds.
or ......... min. ?
and that death occurred, on the date stated above, at.
„.m.
The CAUSE OF DEATH* was as follows :
Cerebral hoemontage
... (Duration) ...
............. yrs.
ds.
. ............
Contributory ...
(SECONDARY)
Duration
.... yrs.
............... mos.
ds.
Archive & cobora
, M.D.
(Signed)
Du, 23, 1916 (Address).
Chilenafora, 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).
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 ..
DATE OF BURIAL
19 PLACE OF BURIAL OR REMOVAL StJoseph Cem.
..............
......
1918
20 UNDERTAKER Matter Perhaus
ADDRESS
Chelmsford
Filed. Dec. 24, 116 Edward . Bobbing
....
6 REGISTRAR
219 Cheimaford
(City or town.)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
6 SINGLE.
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
I HEREBY CERTIFY that I attended deceased from
17
Dec.19
196
Dec. 21. 1916
that I last saw h Mnalive on
Dec. 21, 1916:
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Chelmsford
10 NAME OF
FATHER
Charles . Sweeney
11 BIRTHPLACE
OF FATHER
(State or country)
Lowell Mann.
12 MAIDEN NAME
OF MOTHER
agnes Sullivan
18 BIRTHPLACE
OF MOTHER
(State or country)
Lowell Maks.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Cheg & Sweeney
...... ....
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 arc 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 (rctired, 6 yrs.). For persons who have no occu- pation whatever, write None.
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