USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 18
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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 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, 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 (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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
(No.
Steadman
St.
Ward)
...
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Still born Brown
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] .... @RESIDENCE Steadman Dr. Cheland Registered No. MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED.
OR DIVORCED
(Write the word)
· DATE OF BIRTH
107-1917
(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
18 BIRTHPLACE
OF MOTHER
manE
(State or country)
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
0
yrs.
0
mos.
ds.
If LESS than
t day ........ hrs.
or
.min. ?
10 NAME OF
FATHER
William Brown
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland
12 MAIDEN NAME OF MOTHER many Davidromeo
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
han many Brown
(Address)
16 nov.7. 1917 Gerard tRolling Filed
..........
REGISTRAR
16 DATE OF DEATH
...
(Month)
(Day)
(Year)
17 1 HEREBY CERTIFY that I attended deceased from
191.
....... , to
191
that I last saw h ....
alive on
191
...-
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Stillborn
... (
(Duration)
.yrs.
mos.
ds.
Contributory ... (SECONDARY)
(Duration) .. yrs.
mos.
ds.
2
-
M.D.
(Signed) nom times (Address) 503 Sum Kedy
* 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
DATE OF BURIAL
NOV8 1912
20 UNDERTAKER
young+ Blake.
ADDRESS
Prescott. st.
43
68
7
1914
1
. (Year)
...
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," "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, peritonaeum, ctc., Carcinoma, Sar- roma, 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: 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," "Senile," ctc.), "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, ctc.
R. 15-8-'15. 100,000.
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 South Chelmsford (No
St. :
Ward)
(Cityor town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
69
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
4 COLOR OR RACE
Whiten
5 SINGLE,
MARRIED.
WIDOWED,
· DATE OF BIRTH
april
11
1800
.........
(Month)
(Day)
(Year)
PAGE
67 %
7
........... yrs ..
... mos ..
ds.
Or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Railroad
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
activelot N.t.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Gill Man.
12 MAIDEN NAME
OF MOTHER
Ellen Willis
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant),
Mis William Belleville
(Address)
bouche chelesfur.
16 Nov.11, 1917. Elmond Y, Robbins REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH nor 11
(Month)
(Day)
1917 (Year)
17
I HEREBY CERTIFY that I attended deceased from
Nov. 2
........
1917, to
nor 8
1917
....
....
1917
that I last saw how alive on.
nor. 8.
.... .
and that death occurred, on the date stated above, at 2-30Pm.
The CAUSE OF DEATH* was as follows :
(Duration)
.yrs.
mos.
100
ds .
.......
Contributory. (SECONDARY)
(Duration)
....... yrs. ..
.............. mos.
.ds.
(Signed)
Arthur 4, Ocobora
M.D.
201.12, 1917 (Address).
Chelunsford, 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.
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 Hinsdale N. H
DATE OF BURIAL
Nor.13, 191
....... ,
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford.
important. See instructions on back of certificate.
10 NAME OF
FATHER
Procter a. Roberto
If LESS than I day, ........ hrs.
Trading alancon Roberto
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
....
@RESIDENCE
Quiney Mars.
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 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 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) ; Tubcr .
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 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.
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
PLACE OF DEATH
. Vnilsford
(No
в Daislable Cted
St.
-
(City or town.)
[If death occurred in e hospital or institution, give its NAME instead of street and number.]
Marie Gaudette
saudette
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.}
@RESIDENCE
Davistable Road, No. Chelmsford
Registered No. 70
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
211 - 24
6 DATE OF BIRTH
(Month)
(Day)
C 1/10 (Year)
7 AGE
If LESS than I day, ........ hrs.
EN
mos.
ds.
Or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
.
BIRTHPLACE K: Chelicitar (State or country)
Contributory ... (SECONDARY)
.. (Duration) ...
mos.
ds.
10 NAME OF
FATHER
r
11 BIRTHPLACE OF FATHER (State or country)
* 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.
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
(Informant)
(Address)
6 Atunnotable Del. I. C.
16
Filed Nrv. 12. 1917Edward X. Robbing REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE, OF DEATH
( found )
for
12
(Month)
(Day)
1917 (Year,
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows: · Cerebral Paralysis. Sudden Found dead we tak by wir at 800 Rla
Sun alte at 6.00 am. )
(Duretion)
yrs.
.mos.
ds.
(Signed)
Jur. 12.
1917
(Address) ..
MEDICAL EXAMINER
PARENTS
12 MAIDEN NAME OF MOTHER
1
13 BIRTHPLACE OF MOTHER (State or country) Illares.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
DATE OF BURIAL
Lov, 13 .- 1917
ADDRESS
:0 UNDERTAKER
1
Ward)
2
M.D.
.yrs.
در
a. Cuchar bauch-
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 cngincer, 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) Forcman, (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 laborcr, 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 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, peritonacum, 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 (discase 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 septicacmia," "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 (c. 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, ctc.
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.
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
..............
(No
St. :..... .. Ward)
(City of town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Elisabete aun Fiske
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Club
Und. Mars.
Registered No. 71
PERSONAL AND STATISTICAL PARTICULARS
SEX 7
L' COLOR OR RACE Write
SINGLE
MARRIED
WIDOWED. /
Worried
· DATE OF BIRTH
..
(Month)
(Day)
' AGE
If LESS than I dey, ........ hrs.
5
ds.
or
........ min. ?
8 OCCUPATION
(e) Trade, profession, or
particuler kind of work.
at home
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Chelmsford
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Chelmsford.
12 MAIDEN NAME OF MOTHER Celia Burrows
13 BIRTHPLACE OF MOTHER (State or country: New perweek V.H
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mr. I.E. Warren (das)
(Address)
Clicen chard. Mais
15 Filed 200.16. 1917 Edward Jv Robbing REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
november
16ª
(Month)
(Day)
1917 (Year)
17
I HEREBY CERTIFY that I attended deceased from
nov. 12th
. 1917, to
nov. 1600
1917
that I last saw her alive on.
nov. 15 1
and that death occurred, on the date stated above, at ...
5g.m.
The CAUSE OF DEATH* was as follows :
Cerebral harmonhache
(Duration)
... yrs.
......
mos.
6
ds.
Contributory ..
Senile -
(SECONDARY)
(Duration) 966 yrs
yrs. I mos.
ds.
(Signed)
amarantowad.
M.D.
2101.17, 1917 (Address)
Chehushard 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).
In the
.
At plece
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 Forefathers Cem
DATE OF BURIAL
Nov. 15
.....
1917
20 UNDERTAKER
Walter Perham
ADDRESS
Chelus food.
.....
10 NAME OF
FATHER
John Parklust
9+
... yrs.
5
mos.
11 1823 (Year)
Elisabeth. Parkhurst. Benj. M. Fiske
Chelmsford 0
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 naturc of the business or industry, and thereforc 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 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.
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