USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 15
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culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, ctc., 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- acmia" (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 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, 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.
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 East Chelmsford (No Gorham &
St. :
Ward)
(Cityfor town.) fIf death occurred in a hospital or institution, give its NAME instead of street and number.]
Rebecca Elizabeth Whitcomb 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.I. ( @RESIDENCE East Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
7
4 COLOR OR RACE
White
$ SINGLE,
MARRIED,
WIDOWED,
' DATE OF BIRTH Dec.
17 $40
(Month)
(Day )
(Ycar)
PAGE
71 yrs
yrs.
If LESS than I day, ........ hrs.
8
mos.
20
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)
Boxford Mass
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Boxford Mark.
12 MAIDEN NAME
OF MOTHER
Martha Stiles
| 18 BIRTHPLACE
OF MOTHER
(State or country).
Varde andover Ma
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
I. v. whitcomb
(Address)
East Clubenfund
16 Filed Sept. 2, 1997 Edward , Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sept.
6
1917
....
(Month)
(Day)
(Year)
17
July
11916 to
Sept. 5,
1917
......
....
191.
that I last saw her alive on.
Left 5
2
and that death occurred, on the date stated above, at 2 am.
The CAUSE OF DEATH* was as follows :
Carcinoma of rection .
about 2 mars
casa (Duration).
............. yrs. ..
mos.
ds.
Contributory .. (SECONDARY)
..... (Duration)
.... yrs.
mos.
ds.
(Signed)
Sept 7, 1917
(Address).
Chelmsford, 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
PLACE OF BURIAL OR REMOVAL Redawwvad lin North andover Mars
DATE OF BURIAL
1917
ADDRESS
20 UNDERTAKER
Walter Perham
Cheluifind
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
10 NAME OF
FATHER
Samuel Carlton
....
M.D.,
I HEREBY CERTIFY that I attended deceased from
Registered No. 56
Rebecca & Carlton
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 eaclı 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 Scrvant, 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 (retircd, 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 origir ings definite; avoid use of “₸ sms);
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 onc supposed to be due to Alcoholism, ctc.
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 AGE PARENTS (Address) important. See instructions on back of certificate. 16 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
Chelmsford
(No.
Hunt Road
St. :
Ward)
(City of town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Richard Syen Hulslander
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
fapt.
...
(Month)
8
.,
1917
....
(Day)
(Year)
· DATE OF BIRTH
march
2 1917.
(Month)
(Day)
(Year)
If LESS than
[ day. ....... hrs.
0
..... yrs.
mos.
6
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)
Chelmsford
10 NAME OF
FATHER
Louis Fe Hablando
11 BIRTHPLACE OF FATHER (State or country) Franklin Mars
12 MAIDEN NAME
OF MOTHER
Jennie Morrison
13 BIRTHPLACE
OF MOTHER
(State or country)
Cape Breton
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mro of FT Hulalandes
Filed. Seft. 9, 191 7 Codwar di Robbins
REGISTRAR
.... (Duration) .
.... yrs.
.mos.
Contributory ..
acedvers
(SECONDARY)
(Duration) .
.......
... yrs.
... mos. .
(Signed)
averla, M.D.
461.9. 1917 (Address)
Westand, Mass
* 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 ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Pine Ridge Cem
DATE OF BURIAL
Salat 10, 1917
ADDRESS
20 UNDERTAKER Walter Parka
32 Chelmsford
5%
4 COLOR OR RACE
white
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Registered No.
17
I HEREBY CERTIFY that
attended deceased from
Sept 8
1917, to
.
....
1917,
that I last saw hAMalive on.
Supr 8,
. 1917.
and that death occurred, on the date stated above, at/
The CAUSE OF DEATH* was as follows :
3/
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 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 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, pcritonaeum, 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 merc 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.
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.
1 PLACE OF DEATH
The Conunmuuralth of Massachusetts STANDARD CERTIFICATE OF DEATH
33 Chelmsford
.. Ward)
(City or lowp.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
william mercier
{If married or divorced woman or widow
give maiden name, also name of husband.1
@RESIDENCE
2. Chelmsford
Registered No.
58
PERSONAL AND STATISTICAL PARTICULARS
S SEX
4 COLOR OR RACE
-
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED wie
(Write the word)
" DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
44 . 2
mos.
ds.
or ........ min. ?
-
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Datorer
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Canada
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Damada
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE OF MOTHER (State or country)
Canada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Bru Wm Mercier
(Address)
no. Chelmsford
16 Filed. Soft. 13, 1996 devand Rthing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jeps
(Month)
14
1917
..... , ......
(Day)
( Year)
17 I HEREBY CERTIFY that I attended deceased from aug 9, 1917 o Sept 14 1917 ...... that I last saw hualive on Self 13 ....... . 191.7. and that death occurred, on the date stated above, at & am. The CAUSE OF DEATH* was as follows :
Pul. Tuberculosis
2
.... (Duration
................ mos.
ds.
Contributory General Debility
(SLCONDARY)
(Duration)
.........
.... yrs.
mos.
ds.
James IHaben,
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
In the
of death.
.... yrs.
.......
... mos.
.......
ds.
. ...........
ds .............
State.
... уге.
... mos.
Where was disease contracted, If not at place of death ?
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL it Josephis
DATE OF BURIAL
Lepl 17 1917
20 UNDERTAKER
2. albert
ADDRESS
.....
...............
If LESS than
1 day ........ hrs.
MARGIN RESERVED FOR BINDING
10 NAME OF
Bummereier
(Signed)
Sept13, Foi 7
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, Architcet, 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) Salcs- 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 (rctired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-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-
no. chelimotal
culosis of lungs, meninges, peritonacum, ctc., 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 .; Broneho-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," "Uracmia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify ali diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieacmia," "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.
Rolfin
233 Helproll
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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmsford IN Ganham Child of John P and mable a Sthover.
St. ;.
Ward)
.......
@RESIDENCE
Case Chelmsford Macs
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1º DATE OF DEATH
.
Sunt 23
191.
(Month)
(Day)
(Yea
17
I HEREBY CERTIFY that I attended deceased from Left. 23, 1917, to Chill. 23, 19 7
that I last saw her alive on Left 20, 1917 and that death occurred, on the date stated above, at 1000 m
The CAUSE OF DEATH* was as follows :
Premature Births
(Duration)
... yrs.
mos.
(SECONDARY) ................................... ......
(Duration)
.............. yrs.
.... mos.
ds
William Plantes Me
(Signed)
11.24. 1917 (Address).
53
Centraliz
* 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.
. ....
5 .............
Where was disease contracted, If not at place of death ?....
.......
Former or usual residence. ....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Wpt 25
191
.... 1
18 Filed_ Sept 24, 9 7. Edward + Robbins
REGISTRAR
34
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
59
Registered No.
[If married or divorced woman or widow
give maiden name, also name of husband.]
3 SEX
4 COLOR OR RACE
Firmale White
5 SINGLE,
MARRIED,
WIDOWED.
OR DIVORCED
(Write the word)
· DATE OF BIRTH
Just 23
(Month)
(Day)
' AGE
-
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
PARENTS
1ª BIRTHPLACE
OF MOTHER
(State or country)
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
..... yrs.
... mos.
ds.
If LESS than
I day .......... hrs.
or ........ min. ?
9 BIRTHPLACE
(State or country) C
East thelost and how contributory.
10 NAME OF
Jahn P Sthorea
porer
11 BIRTHPLACE
OF FATHER
(State or country}
try Cancard NH
12 MAIDEN NAME
OF MOTHER
Mable Britwell
Lawell Mace
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .
Dam P Olhares
(Adress) East Chelansford Mas Caron Cemetery
20 UNDERTAKER
John a Wembeck
ADDRESS
awell mach
.......
1967
(Year)
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise 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 occupation 3 a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive cngincer, Civil engineer, Stationary fireman, etc. But in many eases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housc- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At homc. Carc 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 (rctircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
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