USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 13
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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:
4
Deaths following injury or violence, as Burns, Falls,
1
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.
¿ SEX Female " AGE 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
PLACE OF DEATH
Chelmsford
.(No.
......
;......... ....... Ward)
........ ...... (City ør town.) Elf death occurred in a hospital or institution, give its NAME Instead of street and number.]
Marietta Byany
*FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.1 @RESIDENCE Chelmsford
John
Registered No.
4.8
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Widno
15 1844
(Month)
(Day)
(Year)
If LESS than 1 day ......... .
73
.yrs. 6
mos.
17 ds.
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) ...
9 BIRTHPLACE
(State or country)
no. actor
10 NAME OF
FATHER
Archerich Rouillard
11 BIRTHPLACE
OF FATHER
(State or country)
Gekkerell
12 MAIDEN NAME
OF MOTHER
Sarah Potter
13 BIRTHPLACE
OF MOTHER
(State or country)
Concord
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mas G. E. Dutiny
(Address)
Chelmsford
16
ana 3, 197 Edward fr Robbing
Filed
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
aug.
(Month)
(Day)
,
19119
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Jan. 16
1916 to
aug. 1
.. 1917.
....
that I last saw he alive on.
July 20, 1917
.....
and that death occurred, on the date stated above, at / a.m.
The CAUSE OF DEATH* was as follows :
Cerebral embolism.
.... (Duration) .
.... yrs.
.mos.
ds.
Contributory ............
semle, 4 mevirus
(SECONDARY) attacks
/ VIS. 6
.. (Duration).
mos.
ds.
(Signed)
amara stoward
M.D.
Qua- 3
. 1917 (Address)
Chelmsford
* 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
In the
of death ..
yrs
mos.
ds.
State ....
mos.
ds
........... yrs.
...
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Hartford Que.
DATE OF BURIAL
aug 3
1912
20 UNDERTAKER
Water Perham
ADDRESS
Chelmsford.
St. :
23 Chelmsford
few minutes
$ DATE OF BIRTH
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 enginecr, 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 naturc 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. Thc 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 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 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 definitc; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," " An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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 8. Belle Billinger
lenge.
13 BIRTHPLACE
OF MOTHER
(State or country) Quebec, Canada.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ..
John f. Howard
(Address) Chelmsford, Mack.
16 Filed aug 2, 1917 Edward J. Robbers
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male.
4 COLOR OR RACE
White
5 SINGLE
MARRIED
Single.
OR DIVORCED (Write the word)
(Month)
(Day)
191.7. ( Year)
6 DATE OF BIRTH
April
(Month)
2.5, 1909.
(Day)
(Year)
7 AGE
If LESS than I day, ........ hrs.
8+
yrs.
3
.mos.
7
.ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
School Boy.
(b) General nature of industry, business, or establishment in which employed (or employer).
School Boy.
(Duration) .
....... mos. ds.
9 BIRTHPLACE
(State or country)
Dracut, Mace.
Contributory. (SECONDARY)
(Duration)
yrs. 1 mos.
... ds.
(Signed)
M.D. .
Lucy 2 1917 (Address).
.
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. ...
In the
.mos. .......
ds ..
........ ....
Where was dlsease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL riverside Cemetery. No. Chelmsford Mark.
DATE OF BURIAL
Aug 4, 1912.
20 UNDERTAKER GromHealey
ADDRESS
79 Branch 8%.
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH No. Chelmsford .(No.
y un ul. Howard. fr -
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
St.
Ward)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
49
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
17
I HEREBY CERTIFY that I have investigated the ! death of the deceased. 7 The CAUSE OF DEATH* was as follows : Durum + - linedental
2
sai citula
-
10 NAME OF
FATHER
John A. Howard.
11 BIRTHPLACE OF FATHER (State or country) Ont. Canada.
24 No. Chelmsford (tor tow w.)
MARGIN RESERVED FOR BINDING
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- 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, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, ete. But in many cases, especially in industrial cinployments, 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 faet may be indieated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- CASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cerebro-spinal fever (the only definite synonym is "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- comú, ., ... (namc origin: "Caneer" 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 symptomatie), "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 misearriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State eause 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 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, ete.
1. Deaths under eireumstanees unknown, as A person found dead, ete.
R 16. 11-'16. 5,000.
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
PLACE OF DEATH Lowell mars (No. St. John's Hospital
St. i ............
.. Ward)
Lowell (City or town.) [if death occurred in a hospital or institution, give its NAME Instead of street and number.]
James H. McDonald.
$FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
no. Chelmsford mass
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
male white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word married
$ DATE OF BIRTH
(Month)
(Day)
TAGE
38
+++yrs. mos. . .......................
.......... min. ?
& OCCUPATION
(a)' Trade, profession, or
particular kind of work .....
Hardman
(b) General nature of industry. business, or establishment in which employed (or employer) ........
Gas. Co
9 BIRTHPLACE
(State or country)
Tewksbury mass.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) freland
12 MAIDEN NAME
OF MOTHER
Elisabeth Keene
Rene
18 BIRTHPLACE
OF MOTHER
(State or country)
Ireland.
1ª THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Loretta mc Donald
(Address)
no Chelmsford
1% Filedwg It vo Vichen Eluso
REGISTRAR
...
I HEREBY CERTIFY that I attended deceased from
.......... (Year) July 1" 1911, to august 10, 1916 that I last saw bumalive on .... F
10 191.
and that death occurred, on the date stated above, at a.
....
The CAUSE OF DEATH* way as follows :
Cerebral Hemorrhage
.(Duration) .................... ..................................... .
. Contributory (SECONDARY)
(Duration)
.......
... mos. .
... da
(Signed)
James tobarna
M.D. Quegrillo (Address) no Chelmsford ......
* 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 In the of death .. .yrs. ........ mos. ......... .ds. State ............ yrs. ... ds ...........
Where was disease contracted, If not at place of death ?. Former or usual residence. ...... -
1 PLACE OF BURIAL OR REMOVAL DATE OF BURIAL St. Patrick Cemetery bug, 13 191
20 UNDERTAKER P.H. Savage
ADDRESS
Lowell.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
25
50 1224
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
august 10
(Month)
(Day)
191. (Year)
,
10 NAME OF
FATHER
Henry Mc Donald
If LESS than
t day ......... hrs.
-
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precisc 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 naturc 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) Forcman, (b) Automobile factory. The material worked on may form part of the sccond 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 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 cercbro-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, Nu coma, etc., of. (name "Cancer" is less definite; avoid use of "Tumor" for MA "lasms) ; Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (sceond- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (discasc causing deatlı), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Scnile," ctc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old agc," "Shock," "Uracmia," "Weakness," etc., when a definite discasc 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- 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 Chelmsford mentre Mass.
.St .;
.Ward)
(City or,town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Pare & Halve ne Me Larney
*FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford Centre
Patrick 7.
Registered No.
L
51
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
& SEX
+ COLOR OR RACE
Female White
5 SINGLE
MARRIED,
WIDOWED.
OR DIVORCED
(Write the word)
· DATE OF BIRTH
148/27
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day ......... hrs.
35
..... yrs.
mos.
1
... 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)
Lowell mars.
10 NAME OF
FATHER
Varices & m
barne
11 BIRTHPLACE OF FATHER (State or conntry) Powell Mass,
12 MAIDEN NAME
OF MOTHER
Pase Het Nally
18 BIRTHPLACE OF MOTHER (State or country)
Sulaud /
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Patrick A. Halus
(Address)
Chelmsford Chiaes
15 Filed Una 13, 1917 Edward . Robbins
REGISTRAR
...
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
................ 1917, to
aug. 12, 1917.
that I last saw ha alive on.
aug 11, 1917.
and that death occurred, on the date stated above, at 40.m.
The CAUSE OF DEATH* was as follows :
Duoti Endocarditis
(Duration)
5
mos .
ds.
Contributory ...
............
Rheumatism
.... (SECONDARY)
(Duration) .
6
.. mos.
........... yrs. ....
.......
ds.
(Signed)
amara forward
M.D.
Case 13, 1917 (Adres).
Chelmsford
* 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.
................
mos.
ds .....
In the
Where was disease contracted, If not at place of death ?..... ......
Former or usual residence.
............
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL St Patricks Leve aug 14. 1917
ADDRESS
10 UNDERTAKER Ger. B. C Ter
,26
Chelineford
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
PARENTS
16 DATE OF DEATH
1917
.yrs ..
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 enginecr, 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 needcd. 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. - 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: Ccrebro-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-
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