USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 16
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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 fercr (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 lung aringes, peritoneum, etc., Carcinoma, Sar-
coma, etc., of. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular hcart discasc; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced not be stated unless im- portant. Example: Mcasles (disease eausing 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," ctc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the eause. 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 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 eircumstances unknown, as A person found dead, etc.
1
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH to. Undusford
(No. Friction
Julie request
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Unication It. No. Chelmsford.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED WIDOWED, OR DIVORCED (Write the word)
marier
6 DATE OF BIRTH
(Month)
(Day)
1 (Year)
7 AGE
59
.yrs.
mos.
ds.
or ....... min. ?
8 OCCUPATION
Housewife.
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) ..
(Duration)
... yrs.
mos. ds.
Contributory. (SECONDARY)"
... (Duration)
.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, OR RECENT RESIDENTS).
At place
In the
mos.
ds
Where was disease contracted, If not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL Ir Jaseph's
DATE OF BURIAL
Ocr. 5.1917.
(Address)
no. Chilinsford
15 Oct. 5. 1917 Edward & Rothbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
formal
(Month)
(Day)
1914
(Year
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was/as follows : sabes porsains (Loose lor itayra) I'll OTE 5 years ~1to hundreal sundance for
9 BIRTHPLACE (State or country) 0 mals
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Gaspard nearer.
35
(City or town.)
St.
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Grand-
Farband reault
Registered No. 60
10 UNDERTAKERY
ADDRESS Lower 171 arken
(Signed)
cet 4
1917
of death.
yrs.
mos.
ds.
State
... yrs.
(Address).
If LESS than
1 day ......... hrs.
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," ctc., without more precise specification, as Day laborer, Farm laborer, Laborcr - 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 discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid, fever (never rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of. ........... .(name origin: "Cancer" is Icss definite; avoid use of "Tumor" for malignant ncoplasms) ; Measles; Whooping cough; Chronie valvular heart discase; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles. (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," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "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," ctc. State cause 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 carbolie 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 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, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R 16. 1-'17. 10,000.
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
important. See instructions on back of certificate.
PARENTS
(State or country) myChelmsford
12 MAIDEN NAME OF MOTHER~ attie (Is good
13 BIRTHPLACE
OF MOTHER
State or country: Went ford Mais
14 THE ABOVE IS TRUE TO THE BEST ORMY KNOWLEDGE
(Informant)
G.C. Spaulding (Som)
(Address)
16 Filed Oct. 10, 1917 Edward &. Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Det
9
.
191.7
.........
((Month)
(Day)
( Year)
· DATE OF BIRTH Sint
25
18.30
(Year)
(Month)
(Day)
TAGE
If LESS than Į day ......... hrs.
87
yrs. 0 mos. 14 ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Farmer
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or countryY
Chelunsford.
........... (Duration)
................ yrs.
................ mos.
.........
ds.
Contributory ..
(SECONDARY)
(Duration)
.... yrs.
mos.
.ds.
........
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.
State ...
yrs.
.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
Trefactus Cem. Chuchustung Klet. !!
191
7
20 UNDERTAKER
Walter Tenham
ADARESS
36
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
........
(City/of town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
George. Spaulding
[If married or divorced woman or widow give maiden name, also yame of husband.] @RESIDENCE Chelmsford
Registered No. 6/
PERSONAL AND STATISTICAL PARTICULARS
NSEX Male
14 COLOR OR RACE White
SINGLE,
MARRIED,
·
W DOWED.
Ured
...
Det.
17
I HEREBY CERTIFY that I attended deceased from
Qel- 1.
1917, to
1919
....
that | last saw h
alive on.
191/
and that death occurred, on the date stated above, at 165 m.
The CAUSE OF DEATH* was as follows :
Sifter Cyclitis
10 NAME OF
FATHER
alphen Spaulding
11 BIRTHPLACE
OF FATHER
(Signed)
1. 01-13, 1917 (Address).
....
1 PLACE OF DEATH Chelmsford Man (No)
...... (C. Weattend d.
St. ;..
Ward)
.....
2 FULL NAME
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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 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 enginecr, 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) Groccry; (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 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," unqualificd, 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- 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 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 supposcd to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
1917 53
1864
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
722 Chelmsford
.(No
Newfield
St. :
Ward)
[If death occurred In e hospital or institution, give its NAME instead of street and number.]
John Holgate
? FULL NAME
[If married or divorced woman or widow/
give maiden name, also name of husband.]
@RESIDENCE
Newfield St. Nr. thelma.
62
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
8 SEX
Male.
' COLOR OR RACE
White
& SINGLE
MARRIED Widowed.
WIDOWED
OR DIVORCED
(Write the word)
· DATE OF BIRTH
July 25
(Monthy
(Day)
18.64
(Year)
7 AGE
If LESS than 1 day ......... hrs.
53
.... yrs.
2
mos,
16
ds.
........ min. ?
8 OCCUPATION
(a) Trede, profession, or
particular kind of work
Operative.
(b) General nature of industry,
business, or establishment In
which employed (or employer) ........
Operative.
9 BIRTHPLACE
(State or country)
England.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
England.
12 MAIDEN NAME
OF MOTHER
Charlotte More.
17 BIRTHPLACE
OF MOTHER
(State or country)
England.
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Benjamin Holgate
(Address)
57 Coral 88
16 Filed _. Cent. 11 19) ZEdward Si không ........
REGISTRA !!
17 HEREBY CERTIFY that I attended deceased from
o CET 11 . 1917. that I last saw bez alive on Cent 11, 19 and that death occurred, on the date stated above, at.
4Pm
The CAUSE OF DEATH* was as follows :
.... (Duretion).
... yrs ...
................. mos.
ds.
Contributory
(SLCONDARY)
Tere(puration).
........ (Duration)
.......
..... yrs.
mos.
.. ds.
M.D
(Signed)
10/ 11, 1917 (Address) 55 Central
* If death followed Injury or violence the certificato of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OS RECENT RESIDENTS).
in the
At place
of death,
.. yrs.
. mos.
... ds.
State ............ yrs.
............ mos.
da ...
Where was disease contracted, if not at place of death ?
Former cr usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Riverside Cemetery Oct, 14, 1917.
20 UNDERTAKER
Gro Matealey.
ADDRESS
19 Branch 8%.
16 DATE OF DEATH
Oct.
11.
.... ,
1917
(Month)
(Day)
( Year)
.......
..........
10 NAME OF
FATHER
John Holgate.
3, No. Chelmo. (City of town.)
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 linc will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dcaler," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ctc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who reccive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At homc. 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 discasc. Examples: Cerebro-spinal fevcr (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, cte, ^ , Dar-
coma, etc., of .. . (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ctc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (disease causing death), 29 ds .; Broncho-pncumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mcrely symptomatic), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Scnile," 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 discases 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 dcad, etc.
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, Lucas (No)
huddlesex
7
D. Holt
St.
Ward)
Registered No.
63
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Det.
12 97
(Year
(Month)
(Day)
17
| HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows: mural titulo- delisono.
I Found dead in home-14 23
To have, istico Felavons - 40
Medical attendance for a year.)
8 (Duration).
yrs. ....
... mos ..
2
ds.
Contributory.
sobral staumorrhage
(SECONDARY)
.. (Duration))
:mos. ds.
(Signed)
Show ensuite
M.D.
11.2017
(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 disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
March
Ed
10 UNDERTAKER Young & Blake
ADDRESS
33 Prescott.
191
15 Filed Oct. 13, 1917 Edward DROthing
REGISTRAR
35
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
George
2 FULL NAME
[If married or divorced woman or widow
give maiden name, alsó name of husband.]
@RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR QR RACE
whit
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
aug18-1830
(Month)
(Day)
7 AGE
87.
8 OCCUPATION
Retired
(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)
Temple N.K
10 NAME OF
FATHER
Joseph B. Pract
11 BIRTHPLACE
OF FATHER
(State or country)
WiltonN*
12 MAIDEN NAME
OF MOTHER
Clara mansur
PARENTS
13 BIRTHPLACE
WietouN.t.
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
...
.. yrs.
1
.mos. 0
24.
„ds.
or ....... min. ?
(Informant) .
Zur Charles Hals,
Wedwed
1
(Year)
If LESS than 1 day ......... hrs.
(Address)
Ness Chebuchard
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 engincer, 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," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborcr, 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. 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 (rctircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
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