USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 19
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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 rc- 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 discasc 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.
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.
(No
SEX
4 COLOR OR RACE
White
Male
5 SINGLE
MARRIED,
WIDOWES
OB DIVORCED
· DATE OF BIRTH
Nov.
(Month)
(Day)
? AGE
8 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
PARENTS
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
0
.. yrs.
0
mos ..
0
.ds.
06 1917
Year)
If LESS than
1 dal .. hrs.
or ......... min. ?
10 NAME OF
FATHER
Odber E Robinson
11 BIRTHPLACE
OF FATHER
(State or country)
Rt. Jolm n.B
12 MAIDEN NAME
OF MOTHER
adella moree
13 BIRTHPLACE
OF MOTHER
(State or country)
searchort me.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(e. E Robinson (fatur)
(Address)
15
Filed. Jan1/ 1917 Edward ST Rolling REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Mr.
17
(Month)
(Day)
1917 (Year)
17 I HEREBY CERTIFY that I attended deceased from NOT. 16. 1917 to ‹
2. 17 97
that I last saw havalive on
Nr. 17. 197
and that death occurred, on the date stated above, at,
m.
The CAUSE OF DEATH* was as follows :
Patent Framin Cralio
(Duration) .
... yrs.
mos. ......
2 day)
Contributory
(SECONDARY)
(Duration)
yrs.
.. mos.
2 .0
.....
(Signed)
Q- E. Shar
M.D.
... .
mr20
1911 (Address).
fress) 137MM//S1
* 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.
In the
mos.
ds.
State ...
..... yrs.
mos.
ds.
......
Where was disease contracted, If not at place of death ?.. .... Former or usual residence. ......
1.PLACE OF BURIAL OR REMOVAL Pine Ridge Sem.
DATE OF BURIAL
No. 19. 1917
20 UNDERTAKER
ADDRESS
Tallin Pechan Chulinfo.
Chelmsford (City or town.) [If death occurred in Ward) a hospital or institution, give its NAME instead of street and number.]
1PLACE OF DEATH
Chelmsford
Charles albert Robinson
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Littleton Rd. Chelmsford
Registered No.
72
PERSONAL AND STATISTICAL PARTICULARS
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
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 eachı 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 linc 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 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, 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 heart disease; Chronic interstitial nephritis, ctc. 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.
17 branch of
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 stato important. See instructions on back of certificate.
1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Old Tyngslovo Road No. North Chelmsford
Ward) ...
Raymond C. Benest 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE No. Chelmsford.
Registered No.
73
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
& SEX
Maler
4 COLOR OR RACE
White.
5 SINGLE,
WIDOWED, Sino
MARRIED,
. Singles
OR DIVORCED
(Write the word)
· DATE OF BIRTH
aux (Month)
11
1908 17
(Year)
7 AGE
If LESS than 1 day ......... hrs.
9
... yrs.
3
mos.
6
.ds
or ........ min. ?
& OCCUPATION (a) Trade, profession, or particular kind of work
school boy
(b) General nature of industry, business, or establishment In which employed (or employer) ..
Heart Failure Fatty Degenerate 1
) BIRTHPLACE
(State or country)
north Chelmsford Contributory
... (Duration) Deglitheria ... yrs. . ...........
10 NAME OF
FATHER
Clarence Beneso
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME OF MOTHER alice C. Clarke
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Clarence Benest
(Address)
north Chelmsford
1%
Filed. Nov. 17, 1917 Edward & Rotting
REGISTRA !!
H
* If death followed injury or violence the certificate of death fust be made out by the Medical Examiner.
In the
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, O9
RECENT RESIDENTS).
At place
ds.
of death.
yrs.
.mos.
ds.
State ..
....... yrs.
. ............ mos.
......
....... .......
Where was disease contracted, If not at place of death ?
Former or usual residence.
1º PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Riverside Cemeter No. Chelmsford Mesa Nov, 17, 1917.
20 UNDERTAKER GromaHealey.
ADDRESS
79 Branch &t.
.mos.
... ds.
(SLCONDARY)
.(Duration) ..
.......
... yrs.
mos. .....
9
da
(Signed)
Ja
M.D.
191 .......
(Address) ..
110. Chelmsford
.............
16 DATE OF DEATH
(Month)
17
19.7
( Year)
(Day)
(Day)
I HEREBY CERTIFY that I attended deceased from
-0010, 1917, to.
Nov. 17. 1917.
that I last saw him alive on ..
Nov. 16. 1917
and that death occurred, on the date stated above, at 11:30 Pm.
The CAUSE OF DEATH* was as follows :
1
Northelmsford (City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
„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 age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborcr, 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, 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," "Senilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old agc," "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.
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
(State or country}
Quetria
na
12 MAIDEN NAME
OF MOTHER
18 BIRTHPLACE
OF MOTHER
(State or conntry)
Questura
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Jako Stretch father
(Address)
Than Leur, 0
16 Filed Nov. 18, 1917 Edward SRollin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
November 18
191.2
(Month)
(Day)
...........
(Year.
DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
romy .... hrs.
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) ...
......
.. ds.
(Duration) .
... yrs.
....
............ mos ..
.......
Contributory.
(SECONDARY)
.. (Duration) .
............... yrs.
...
.mos.
............. „ds
(Signed)
7 EJamnay
M.D.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
.yrs.
In the
... 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
421/199
20 UNDERTAKER
ADDRESS
Chelmsford (City er town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Ward)
hecholas Stretch
Alch
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.1
@RESIDENCE
Than Line
Registered No.
74
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
3 SEX male white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED1
(Write the wordy MALL
17 I HEREBY CERTIFY that I attended deceased trom
191.
....... , to
november 18
1912
that I last saw him alive on
1917
- ........ . and that death occurred, on the date stated above, at 20 m. The CAUSE OF DEATH* was as follows :
Siemature brilh
9 BIRTHPLACE
(State or country)
" Chelans ford
IO NAME OF
FATHER
Total Stretch
........
MARGIN RESERVED FOR BINDING
The Communturalth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH - Chelmsford (No Show aus
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 age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. ..........
.......... .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; Measles; Whooping cough; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old agc," "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.
....... SEX Diale 7 AGE 8 OCCUPATION 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
alandar
oulan
* FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE -
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
Li
15 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
· DATE OF BIRTH 7200. (Month)
23 +312 (Day) (Year)
If LESS than
{ day ......... hrs.
.......... yra. 2
..... mos. .ds.
or ....... min. ?
(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) Lowell ! Man
10 NAME OF FATHER Mantavs
11 BIRTHPLACE OF FATHER (State or country) Cas MERCE
12 MAIDEN NAME OF MOTHER Constanto etamoulis
1ª BIRTHPLACE OF MOTHER (State or country)
REECE
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Soulas
(Address) Chelmsford Man
16 Filed Nov. 25, 1917 Edertrend La Rotis
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Novembre
25
25
1917
(Month)
(Day)
(Year.
17 I HEREBY CERTIFY that I attended deceased trom
.... , , 19 24 of November 1917 .... ...... that I last saw it alive on 24h of November 1919 and that death occurred, on the date stated above, at 120 m. The CAUSE OF DEATH* was as follows : athrepsia ....
.. (Duration)
.. yrs.
mos.
ds.
Contributory (SECONDARY)
mos.
ds
(Signed)
........
forfuncião
M.D
26 Novel 1919 (Adres)
Aule-Mère
* If death followed injury or violence the certificate of death must be made ont by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place of death . yrs.
In the
mos.
ds.
State ...
........... yrs.
......
..... mos.
......... ...............
Where was disease contracted,
if not at place of death ?.
.......................................... Former or usual residence ....
19 PLACE OF BURIAL OR MENOUNA Mas Wetteron lineling
DATE OF BURIAL
Mai 2.7. 1917
A UNDERTAKER
ADDRESS -
Phoneford 50
.St. ;...... .Ward)
(Cityof town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.1
Registered No.
75
Ir.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be 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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