USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 17
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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: Ccrebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, 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 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 dcad, etc.
R 16. 1-'17. 10,000.
.
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 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
11 BIRTHPLACE
OF FATHER
[ country) Maine.
12 MAIDEN NAME
OF MOTHER
Juinda Chaney
13 BIRTHPLACE
OF MOTHER
(State or country)
Chaney Island
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Chelmsford. Khans.
16 Filed. act. 15, 1917 Edward F, Roofing .............-
REGISTRAR
......
elmont P. Sawyer
Registered No.
64
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
COLOR OR RACE
Female White
5 SINGLE,
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
blassied
' DATE OF BIRTH
....
(Month)
17 1874
(Day)
(Year)
7 AGE
If LESS than I day ......... hrs.
„mos.
28
ds
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
......
Cot Stone
(b) General nature of industry, business, or establishment In which employed (or employer).
9 BIRTHPLACE
(State or country)
Maine
0
(Duration) yrs.
5
.. mos.
ds.
Contributory ..
(SECONDARY)
..... (Duration) 7 yrs ..
............... mos,
ds.
.........
(T. Laureo
M.D.
(Signed).
OchIS, 197
(Address) ...
779 MYSQL
* 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 ..
mos.
ds.
State.
.. yrs.
.........
....
Where was disease contracted, If not at place of death ?
Former or usual residence ..... ...............
19 PLACE OF BURIAL OR BEMOVAL -cremation ItCutum, Cambridge
DATE OF BURIAL
cremation
dect 18, 1917
20 UNDERTAKER IL m /f. Daunder
(City or town.)
[If death occurred In a hospital or institution, give Its NAME Instead of street and number.]
2 FULL NAME [If married or divorced woman or widow give maiden name, also namo of husband.1 @RESIDENCE Chimbora, Dass
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
October
(Month)
(Day) 15 ..... 1917 (Year)
.......
I HEREBY CERTIFY thatI attended deceased from 1917, to Get 15 1917. that I last saw hez alive on Och, N, 1917. , at5 0. and that death occurred, on the date stated above, ............ .m. The CAUSE OF DEATH* was Cancer & the Uterino
......
10 NAME OF
FATHER
James T. Farrell
....
The Commmuralth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
St.
Ward)
ADDRESS 217 APPLETON ST.
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 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. Thc material worked on may form part of the second statement. Never return "Laborer," "Forcman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At 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 (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- neumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ..... ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; 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" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," 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, etc.
R. 15. 1-'17. 100,000.
-
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
.... 3 SEX male " 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
1 PLACE OF DEATH North Grubugard (No.
Punton De
St. : Ward)
Cooler In. Knox
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
North Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Jungle
$ DATE OF BIRTH
Frekwauf 18-18746
(Month)
(Day) (Year)
If LESS than [ day ......... hrs.
43
.yrs.
mos.
0
„ds.
or ......... min. ?
8 OCCUPATION
0
(a) Trade, profession, or umberman
particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE
(State or country)
England
10 NAME OF
FATHER
James Perox
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
anne Trang hton
13 BIRTHPLACE
OF MOTHER
(State or country)
Scotland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Rua anni Davil
(Address)
North chelmsford
18 File Oct. 19, 19 Eduard y Retten
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Oav 15-1917.
191
....
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Oct 17, 1917,to.
Det 18, 1917
that I last saw him alive on.
Det 18
1917
and that death occurred, on the date stated above, at 10:38cm.
The CAUSE OF DEATH* was as follows :
Lobar Pneumonia.
4
ds.
.. (Duration
Ciente dil of heart
.mos.
Contributory ....
(SECONDARY)
.. (Duration) ................. yrs. .. mos. ds.
(Signed)
Ittaban
M. D.
Got 19, 1017 (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
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
lavera de
North Chelmsford
DATE OF BURIAL
Our 20.
1917
.....
20 UNDERTAKER
youngT Blake
ADDRESS
33 Precorso.
North Chelmsford
......
(City or town.) [If death occurred In a hospital or institution, give its NAME Instead of street and number.]
Registered No.
65
I
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 applics 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 fircman, 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 entcred 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- LASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
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 necd 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 Aiseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
1
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.
1
R. 15-8-'15. 100,000.
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
PLACE OF DEATH
howell mass.
.......
Lowell Corp. Hospital.
.St .;
Ward)
Lowell (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Joshua J. Davis
* FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
no. Chelmsford mais
Registered No.
66
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
white
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word Married
· DATE OF BIRTH
march
18
(Month)
(Day)
(Year)
7 AGE
If LESS than
f day ......... hrs.
Y ...... yrs. .......
85 yrs. 7 mos.
2
de.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Blacksmith
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Boston, mass.
PARENTS
12 MAIDEN NAME
OF MOTHER
Catherine Parkhurst
11 BIRTHPLACE
OF MOTHER
(State or country)
massachusetts
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Chas J. Davis
(Address) Wollaston, mass
16 Filed Cet 22 2/1/19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
October
20
......
191
.....
(Month)
(Day)
(Year,
I HEREBY CERTIFY that I attended deceased trom
191
........ , to
191.
that I last saw h .............
alive on
191
and that death occurred, on the date stated above, at.
The CAUSE OF DEATH* was as follows : tractura of Right Humerus eight ribe right side left
ffermur and
compound fracture of right femur!
(automobile accident) struck by
automobile an state highway
Contributory ne
(SECONDARY)
.. (Duration)
yrs.
ds.
Thomas B. smith
M.D.
(Signed)
Oct. 21. 1917
(Address).
Lowell
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death
....... yrs. ............ mos.
ds.
State ....
....... yrs.
.. mos.
Where was disease contracted, If not at place of death ?... .... Former or usual residence. .......
I PLACE OF BURIAL (PRO REMOYAYGIN).
DATE OF BURIAL
Oct. 24 1917
1911
20 UNDERTAKER
Geo. W. Healey
ADDRESS
Lowell.
.moF.
10 NAME OF
FATHER
Joshua Davis
11 BIRTHPLACE
OF FATHER
(State or country}
Vermont
892
17
MARGIN RESERVED FOR BINDING
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preeisc statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to eaeli and every person, irrespective of age. For many oeeupations 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, ete. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when necded. 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 specifieation, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the houschold only (not paid Housc- keepers who rceeive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the oceupations of persons engaged in domestie service for wages, as Servant, Cook, Houscmaid, etc. If the occupation has been changed or given up on aeeount 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 oeeu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affeetion 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 eercbro-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., Careinoma, Sar- coma, etc., of ..... (name origin: "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie valvular heart disease; Chronic interstitial nephritis, ete. The contributory (second- ary or intereurrent) affeetion need 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, sueli 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 ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," "PUERPERAL peritonitis," cte. 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 eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deathis of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ete.
4. Deaths under circumstances unknown, as A person found dead, ete.
R 18. 1-'17. 10,000.
. .
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 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
muratHale
'FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Robbing Oliver # Hale
Registered No. 67
PERSONAL AND STATISTICAL PARTICULARS
SEX
' COLOR OR RACE
Female White
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
Write theword)
Widvula
· DATE OF BIRTH
April 906Month) 184 a 4
1
(Year)
' AGE
If LESS than
t day ......... hrs.
68
JA, 6 De 18
ds.
or ........ min. ?
8 OCCUPATION Athird
(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)
Country Vachna WN
10 NAME OF
FATHER/
lecce Robbins
PARENTS
12 MAIDEN NAME
OF MOTHER
rebecca Blanchard
18 BIRTHPLACE
OF MOTHER
(State or country) parkrun
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Charles Hale
Filed (Oct. 27, 1917 Edevard J. Robbins
REGISTRAR
...
(Month)
(Day)
17
I HEREBY CERTIFY that I attended deceased from
Del. 22, 1917, to.
Oct. 27
1917
Del-27
that I last saw h& alive on
191.2
and that death occurred, on the date stated above, at 10 am
The CAUSE OF DEATH* was as follows :
aboutone year.
-((Duration)
............. yrs.
mos.
ds.
Contributory ..
(SECONDARY)
... (Duration)
............. yrs.
................ mos. .ds
(Signed)
001.27.1917
1917 (Address)(
North Chiliustal
* 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.
..........
d ..............
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
(Addres) No Seheleford Nolehelmand Det 30, 1912
ADDRESS
@UNDERTAKER
1
a NANembech bowell
42
(City or town.)
St. ;.... ................. .. Ward)
Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
MEDICAL CERTIFICATE OF DEATH
1ª DATE OF DEATH
October
27
19/17
(Year)
important. See instructions on back of certificate.
...
11 BIRTHPLACE
OF FATHER
(State or country)
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 occupation 3 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 eascs, 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, 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 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.
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