USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 14
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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," "Scnile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "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.
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, ctc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
I PLACE OF DEATH 2 FULL NAME & SEX ' COLOR OR RACE KEmale Huit · DATE OF BIRTH July (Month) (Day) 7 AGE & 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) PARENTS IHodifax 13 BIRTHPLACE OF MOTHER (State or country) (Informant) Arthur Section CAUSE OF DEATH in plain terms, so that it may be properly classificd. Exact statement of OCCUPATION is very .................... y.s. .mos. .... 6 ds.
The Oommmmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
.......
Pincelon M.
Sene Many éclair
aw
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Ho Chelmsford.
PERSONAL AND STATISTICAL PARTICULARS
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED .CC
(Write the word)
/ 1917
(Year)
If LESS than
I day ..
... hrs.
or ........ min. ?
Via Chuharford Mars.
10 NAME OF
FATHER
W. they Leclair
11 BIRTHPLACE
OF FATHER
(State or country)
Canada
12 MAIDEN NAME
OF MOTHER
Mary Carrier
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)
16 File Any /3, 191) Edward A Bathing .....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
13
(Month)
(Day)
191
(Year)
17 I HEREBY CERTIFY that I attended deceased from Rug 11, 1917, to Cinq B, 1911 that I last saw her alive on. a 13. 1917 and that death occurred, on the date stated above, at .... ................... m. The CAUSE OF DEATH* was as follows :
....
Gaolio-Ententis
....
(Duration)
.......... yrs.
......
mos.
ds.
Contributory ...
(SECONDARY)
(Duration)
.mos.
ds.
(Signed)
..........
M.D.
* 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.
In the
ds.
State ............ yrs.
............ mos.
. .......... ... ds .............
Where was disease contracted, if not at place of death 7.
Former or usual residence . .....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Kug 4,
191
20 UNDERTAKER
ADDRESS 217 APPLETON CT.
27 He Chelnford. (City or townĄ [if death occurred in a hospital or institution, give its NAME instead of street and number.]
......
St. Ward)
Registered No.
52
... ................
....
(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, 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 entercd 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 samc 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 lunge - inges, peritonacum, etc., Carcinoma, Sar- coma, etc., of ...... ... (name origin: "Canc . " is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles; Whooping cough; Chronie 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" (mercly symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age,". "Shock," "Uraemia," "Wcakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," "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. 1-'17. 100,000.
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 Nasch Chehussard (No. Highland ave
Still Gow Graus
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
North Cheluntard
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR QR RACE
white
5 SINGLE
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
Que14-1914
-(Month)
(Day)
1
(Year)
7 AGE
If LESS than
1 day ........ hrs.
0
.... yrs .. 0 .... mos. 0 ds.
V min. ?
8 OCCUPATION (a) Trede, profession, or particular kind of work
(b) General nature of industry,
business, or establishment in.
which employed (or employer).
Still Bom.
(Duration)
... yrs.
mos.
ds.
Contributory ... (SECONDARY)
.. (Duration) ... yrs. ................. ................ mos. ds.
(Signed)
M.D.
.... 191 ......... (Address) ...
.....
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
ds.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
In the
of death
.... yrs. ............ mos.
ds.
State ............ y.s.
mos.
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Edson Quintero
DATE OF BURIAL Card/6, 1917
20 UNDERTAKER Having & Blake
,28
March 8th
St. :
Ward)
(City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
53
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
J HEREBY CERTIFY that I attended deceased from
191.
..... , to
191
.....
that I last saw h ...........
191
. alive on.
.......
and that death occurred, on the date stated above, at ....
...........
m.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
North Chelmsford mare
10 NAME OF
FATHER
Fred L. Graus
PARENTS
$11 BIRTHPLACE
OF FATHER
(State or country)
Lowell 891
12 MAIDEN NAME
OF MOTHER
Elser Delang
18 BIRTHPLACE
OF MOTHER
(State or country)
Novascotia
14THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Great. Fraun
(Address) No Childand Mass
16 Filed_ ang 16, 197 Edward . Coffins
REGISTRAR
ADDRESS
33 Percash
(Month)
14
(Day)
191.
(Year)
......
STANDARD CERTIFICATE OF DEATH.
'- of lungs, meninges, peritonaeum, ctc., Carcinome
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
....... .(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" (mere)y 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- 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.
I PLACE OF DEATH
& SEX
--
$ DATE OF BIRTH
7 AGE
/
& 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)
ry)
10 NAME OF
FATHER
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
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
.. yrs.
4 COLOR OR RACE
6 SINGLE.
MARRIED
WIDOWED,
OR DIVORCED UNIC.
(Write the word)
11
(Month)
(Day)
1 (Year)
If LESS than
i day ......... hrs.
, mos.
Or ........ min. ?
11 BIRTHPLACE OF FATHER (State or country) Allconsocket R. l.
12 MAIDEN NAME
OF MOTHER
TEchie DEEney
XILTELL. 1
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Edward Train).
(Address)
Ho Chination
16 Filed deney 18, 19 Edraad I Rollen
REGISTRAFI
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Que
(Month)
(Day)
18
191
(Year)
I HEREBY CERTIFY that I attended deceased from
17
Qua 13, 1917, to.
an 18 1917
...
that I last saw hh alive on
1917.
and that death occurred, on the date stated above,
at Tam.
The CAUSE OF DEATH* was as follows :
Gastro Enteritis
.. (Duration) ............... yrs.
mos.
ds.
Contributory (SLCONDARY)
.. (Duration) .. ... yrs.
mos.
ds.
(Signed)
man. M.D.
(Address).
* If death followed injury or violence the certificate of death most 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
In the
.... yrs.
mos.
ds ......
Where was disease contracted, If not at place of death ?
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL, It Patricks
DATE OF BURIAL
7
191
20 UNDERTAKER
ADDRESS
(City or .\n.) 1lf death occurred in a hospital or institution, give its NAME instead of street and number.]
a. Mardin.
Hermione
? FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Princelow Lt, He Chelnel Registered No.
54
PERSONAL AND STATISTICAL PARTICULARS
MARGIN RESERVED FOR BINDING
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Vrivector
St. :...
Ward)
......
.....
................
................
1 21 „ds.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Prceise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean 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, ete. 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 domestie service for wages, as Servant, Cook, Housemaid, etc. If the oceupation 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 indicated thus: Farmer (retired, 6 yrs.). For persons who have no ceeu- 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 "Epidemie eerebro-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, cte., c
coma, etc., of ...... .. (name origin: "Cancel is les definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, cte. The contributory (second- ary or intereurrent) 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease ean be ascertained as the cause. Always qualify al diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State eause 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 violcnee, 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, cte
4. Deaths under circumstances unknown, as A person found dead, ete.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX 7 AGE 10 NAME OF FATHER 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
West Cheinsiurd
1 PLACE OF DEATH
Chelmsford ....... ... (No
St. ;.
Ward)
(City or town.) [If death occurred in a hospital or institution; give its NAME Instead of street and number.]
2 FULL NAME DrWillard C. Cummings
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
West Carbet Or
Registered No. 3.5 ....
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word)
1
(Year)
86 yrs. 77
mos.
.ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Retired
١
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Maine
11 BIRTHPLACE
OF FATHER
(State or country)
Maine
12 MAIDEN NAME
OF MOTHER
Louise Cailuan
18 BIRTHPLACE
OF MOTHER
(State or country)
Loine
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Na Jar A move
(Address) West Chelmsford
Filed Seht 6 1970 devar dorovfines
REGISTRAR
16 DATE OF DEATH
Sept 5 1917.
191
......
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Queg 25, 1917, to
...........
1917.
that I last saw h w alive on.
....
191.2,
and that death occurred, on the date stated above, at 3.4.5 m.
The CAUSE OF DEATH* was as follows :
Senilità
mos. ds.
Contributory ...
(Hemiplegia
(SECONDARY)
(Duration) 3 yrs.
... mos. .
... ds.
M.D.
(Signed)
Self-6
.. 1917
(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
In the
of death
... yrs.
mos.
ds.
State ............ yTS. ......
... mos.
ds.
Where was disease contracted, if not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL West Chelmsford
DATE OF BURIAL
Sept 7
.... ,
191
7
20 UNDERTAKER
TAR Young ouMBlater
ADDRESS
3.3 Cruscottifx:
...........
........
· DATE OF BIRTH
Oct. 10. 1830
(Month)
(Day)
If LESS than
1 day .......
... hrs.
.........................................
30
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, c. 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," "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 houschold 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-
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