USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 20
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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., Careinoma, Sar- coma, etc., of ....... .(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronie 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," "Hacmorrhage," "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 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
.(No. Church
St. : Ward)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
Stile bom Kolloy
? FULL NAME [If married or divorced woman or widow give maiden name, also name of busband. 1 @RESIDENCE
Church of Porta Chremetorg
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the word)
· DATE OF BIRTH nor. 27
(Month)
(Day)
(Year)
If LESS than { day ........ hrs.
..... yrs. ...... mos.
ds,
........ 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) Lowale man
10 NAME OF FATHER/ Dieward P.
11 BIRTHPLACE OF FATHER (State or country) Wakefiely Maso
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country
north Chelmsford
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant). ) Auchand & Noches
(Address) March Chelmsford
Filed Nov. 27, 1917 Edward Halling REGISTRAR
...........
.......
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 :
Shelton
....... .. (Duration) ............. yrs. . ...
....... ... mos. . .... ds.
Contributory .. (SECONDARY)
.(Duration) ..
....... ... yrs. .... mos. ds.
(Signed) 7 Varney
M.D.
227, 1917 (Address)
MI Chilumfang
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place of death yrs. mos.
In the
ds.
State .....
....... yrs.
mos. ds ....
Where was disease contracted, If not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL Valyuk ameliy
DATE OF BURIAL Mor. 28 191.
"UNDERTAKER
ADDRESS
less
s):
se;
1-
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
SEX auch 7 AGE & 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 .... ......
North Chelmsford
(City or igwn.)
76
Registered No.
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
(Month)
(Day)
191 7 ...... (Year.
17
I HEREBY CERTIFY that I attended deceased trom 191 Har 27 ........ 191 __ 2
.....
........
to
2 7
....
1917
Sar-
STANDARD CERTIFICATE OF DEATH.
-
Statement of occupation. - Preeise statement of oeeu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to each and every person, irrespective of age. For many oeeupations 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) 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 laborer, Laborer - Coal minc, ete. 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 oceupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state oeeupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oecu- 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 aeeepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie 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, ete., Careinoma, Sar- coma, ete., of ....... „(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (sceond- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus." "Old age," "Shoek," "Uraemia," "Weakness," ete., when a definite disease ean be aseertained as the cause. Always qualify all diseases resulting from childbirth or misearriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under tlie provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medieal 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, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be duc to Alcoholism, ctc.
4. Deaths under circumstances unknown, as A person found dead, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX terrale 7 AGE PARENTS important. See instructions on back of certificate. 15 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
APLACE OF DEATH
.(No. Church
St. :
......... Ward)
(City or yówn.) [If death occurred in a hospital or institution, give its NAME instead of street and number.}
File bom Molloy
* 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
which
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
$ DATE OF BIRTH 200.
(Month) (Day)
If LESS than [ day ......... hrs.
.yrs.
mos.
ds.
or ........ min. ?
& OCCUPATION (a) Trade, profession, or particular kind of work
(b) General nature of Industry. business, or establishment in which employed (or employer) ...
9 BIRTHPLACE (State or country) not Worth Chalmoord Mars
10 NAME OF FATHER richard OP
11 BIRTHPLACE OF FATHER (State or country) Wakefield, Mas.
12 MAIDEN NAME OF MOTHER
1ª BIRTHPLACE OF MOTHER (State or country
North Chelmsford
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Orchard IlVolley
(informant) (Address) North Chelmsford
Filed Dar: 27, 1917 Edward Medbring
REGISTRAR
16 DATE OF DEATH
(Month)
27
(Day)
1917
(Year.
27
1917
17
I HEREBY CERTIFY that I attended deceased trom
(Year)
191 ...... , to
Mar 27
191
7
that ! 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
1
(Duration)
.yrs.
mos. .. ds.
Contributory ..............***
(SECONDARY)
(Duration).
............. yrs.
.......
.... mos.
... ds.
Mr. 27, 1917 (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.
în the
.mos.
ds.
State.
.......... yrs.
Where was disease contracted, If not at place of death ?... .... Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
worth Chamaford
191
7
20 UNDERTAKER
ADDRESS
77
Registered No.
MEDICAL CERTIFICATE OF DEATH
......
North Chalneford
(Signed)
J Warmer
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," "Dealcr," 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 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," "Senilc," 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 diseasc, 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.
7 AGE & OCCUPATION (a) Trade, profession, or particular kind of work 11 BIRTHPLACE OF FATHER (State or country) PARENTS important. See instructions on back of certificate. 16 N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
' PLACE OF DEATH Mr. Chelmsford (No Nyugalomra Grad St.
Ward)
(City or town.) [if death occurred in a hospital or institution, give its NAME Instead of street and number.]
Milland Satlett
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Lyngsbord Road
Registered No.
78.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
Dec.
(Month)
191
(Day)
7
(Year)
17
1 HEREBY CERTIFY that I attended deceased from
nov. 30
, 1917 to
191
that I last saw him alive on
m. 30
197
and that death occurred, on the date stated above, at ............... m.
The CAUSE OF DEATH* was as follows :
acuto lobar pneumonia
(Duration)
.. yrs.
mos. ds.
Contributory.
(SECONDARY)
F. H. Laculbert
(Duration)
............. yrs.
................ mos.
ds.
Dec. 4,0 7 (Address) Tungseno Mase
.....
* 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 er usual residence.
19 PLACE OF BURIAL OR REMOVAL
(Informant).
Alexander
bart lett Why
(Address)
Both Thelinesfor mars
Filed Dic. , 199 Edward Robbins
REGISTRAR
5 SINGLE
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH
Sepet
6
1915
(Year)
(Monthy
(Day)
If LESS than I day ........ hrs.
205
......
... yrs.
2
.mos.
.....
.........
.. ds.
Or ........ min. ?
(b) General nature of industry, business, or establishment In which employed (or employer) ....
9 BIRTHPLACE (State or country) Youth Chelwex ford
10 NAME OF
FATHER
Alexandy Doitlett
12 MAIDEN NAME OF MOTHER Mary Gilbert
13 BIRTHPLACE OF MOTHER (State or country) Builing fon Of
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
fele ford 153
DATE OF BURIAL Die 2 19:2
.....
@ UNDERTAKER
ADDRESS 324 mayget If
......
M.D.
Cy
8 SEX
4 COLOR OR RACE
Halv Meter
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) Salcs- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Forcman," "Manager," "Dealer," ete., 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 employcd, 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 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 usc of "Tumor" for malignant neoplasms); Measles; 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," "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 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 caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, ctc.
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.
-
L
2
MARGIN RESERVED FOR BINDING
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.
F
54
(City or town.) [if death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
Still Bow Propio
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Dunstable Rd So Chelmsford In Registered No.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Quale
+ COLOR OR RACE
White
5 SINGLE.
-MARRIED.
WIDOWED
OR DIVORCED-
(Write the word)
· DATE OF BIRTH
(Month)
(Day)
-
(Year)
7 AGE
If LESS than
1 day ........ hrs.
.. y٢٥٠
mos.
ds.
or ......... min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
massachusetts
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Italy
12 MAIDEN NAME
OF MOTHER
Socia Sucio
1ª BIRTHPLACE
OF MOTHER
(State or country)
Italy
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Sabatino Grafico
(Address)
16 Filed. Dec. 3, 1917 Edward & Roofing
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
1917 to. to VIC 2. 1912. : I last saw him allelead Wie 2 197 and that death occurred, on the date stated above, at 10Am The CAUSE OF DEATH* was as follows :
1
.(Duration)
.......
.... yrs.
....
....... mos.
ds.
Contributory ... (SECONDARY)
............. (Duration) ................ yrs. ....
................ mos.
ds.
(Signed)
-
M.D.
ECS. . 1917
(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).
In the
At place
of death
yrs. ............ mos.
ds.
State ....
......... yrs.
.mos.
. ...
ds ...
Where was disease contracted, If not at place of death ?.
Former of usual residence.
13 PLACE OF BURML OR REMOVAL It Patrick
DATO OF BURIAL
Dec 4
1918
20 UNDERTAKER
Wiggins Bros
ADDRESS
415 Lawrence Pt
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
I PLACE OF DEATH
.........
STANDARD CERTIFICATE OF DEATH Junitable Of
St.
Ward)
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH 2 00. 2. 1917 191 (Year)
(Month)
(Day)
10 NAME OF
FATHER
Sabatino Propio
.............
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, Architeet, 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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