USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 21
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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 diseasc. 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
Careinoma, Sar-
eoma, 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, 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 septieaemia," "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.
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
I PLACE OF DEATH So Chelmsford »(No
St. :
Ward)
(City of town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Henry E. Badger
2 FULL NAME [If married or divorced woman op widow give maiden name, also name of husband. @RESIDENCE So Chelafard
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
what's
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manud
$ DATE OF BIRTH mar 14 - 1843 (Month) (Day)
1
(Year)
7 AGE
74
.......
yrs.
9 . 6
mos.
ds.
Or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(Petra
(b) General nature of industry, business, or establishment in which employed (or employer) ....
9 BIRTHPLACE
(State or country)
Warren N.fr
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Sarah Badwell
12 MAIDEN NAME
OF MOTHER
merhum man
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
hur d. E. Badger
(Address)
So Chelunhard
16 Dec. 21 , 1917 Edward J. Robbing Filed.
...... REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec 20-1917
.........
(Month)
(Day)
191
(Year)
17
I HEREBY CERTIFY thet I attended deceased from
Syfte
191
du- 20 1917.
to
.........
that I last saw him alive on
Sze 17
and that death occurred, on the date stated above, at ... [ ........ m.
The CAUSE OF DEATH* was as follows :
Samma of Spleen
(Duration)
1
.yrs. .......
1
.mos. ....
ds.
Contributory ..............
.... (SECONDARY)
.. (Duration) ...
......... yrs.
.... mos.
... ds.
.........
(Signed)
9-5. She
M.D.
49, 19/7 (Address) 137MM Kb
...........
* 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 ....
........ yr$.
............ mos.
............ .............
Where was disease contracted, If not at place of death ?. - Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL.
Pine Grove Connected Manchester N. 58
20 UNDERTAKER young & Blake
DATE OF BURIAL Dec 23. 1917
ADDRESS
....
55 So Chemilard
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
Registered No.
80
. ....
If LESS than
[ day ........ "
10 NAME OF
FATHER
Jonathan Badger.
In the
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- BASE 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); 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," "Hacmorrhage,", "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, etc.
..
R. 15-8-'15. 100,000.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX 7 AGE 10 NAME OF FATHER 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 Commmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
This May Lookcon.
? FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.1 @RESIDENCE no Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
' COLOR OR RACE
6 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
(Month)
(Day)
(Year)
If LESS than
i day ........ hrs.
& 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)
Do. S Fulanafora.
11 BIRTHPLACE OF FATHER (State or country)
60
12 MAIDEN NAME OF MOTHER
Beler Writtenwork
volta
18 BIRTHPLACE
OF MOTHER
(State or country)
Rochdale Eny
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
No Chelmsford Was
(Address)
18 Dec. 21 ,197, Edward YKarting Filed
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dee
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
..
Dee/
.. 1917, to.
Dec 20
1917.
...
that I last saw halive on.
Dec 20
... 1917.
and that death occurred, on the date stated above, at 5-30 m.
The CAUSE OF DEATH* was as follows :
prestation birch
(Duration)
.yrs.
mos.
ds.
Contributory .. (SECONDARY)
(Duration)
........... yrs.
.. mos.
ds.
(Signed)
JEVanner
M.D.
Dec 20 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.
State ...
........... yts.
In the
mos.
ds ...
... ..... Where was disease contracted, If not at place of death ?.
Former cr usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL Lete 31/ 19/7
20 UNDERTAKER
ADDRESS 345 Freelford Sh
5-6
(City or town.)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
St. Ward)
81
Registered No.
20
1917
............. yrs.
mos.
18
ds.
or ......... min. ?
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 cach 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- motivc engineer, Civil engincer, 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 necdcd. 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 laborcr, Laborer - Coal mine, ctc. Women at home, who are engaged in the duties of the household only (not paid House- kcepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (rctired, 6 yrs.). For persons who have no occu- pation whatever, write 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 usc 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 (disease causing death), 29 ds .; Broncho-pneumonia (sccondary), 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," "Uracmia," "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 discase, 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.
1 R. 15. 1-'17. 100,000.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
...
(City or town.)
[If death occurred in a hospital or institution, give its NAME ·nstead of street and number.j
2 FULL NAME Mr Charles Dinneran [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 146. Wrightman St
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH Dec 38
(Month)
(Day)
1912
(Year)
(Month)
(Day)
1
(Year)
If LESS than
1 day ......... hrs.
.yrs. mos. ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Stone Cutter
(b) General nature of industry, business, or establishment in which employed (or employer) ..
New York
John Dinneran
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
Mary Elcot
13 BIRTHPLACE
OF MOTHER
(State or country)
New York
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mrs Ellen Dinnegen
(Address)
146 Wrightman St
16 Filed. Dec. 29, 1917 Edward J Robbing
REGISTRAR
17
.... .....
I HEREBY CERTIFY that I attended deceased from
Dec 25, 1917, to Dea 28
1917.
1917
that I last saw have alive on.
leer 27
... .
... ,
and that death occurred, on the date stated above, at 7450 m.
The CAUSE OF DEATH* was as follows :
Pulmonary Interestedes
Sudary 7 3242
... (Duration).
... yrs.
........ mos.
. ...... ds.
Contributory ...
(SECONDARY)
(Duration).
............. yrs.
................ mos.
ds.
(Signed)
....
Fred &Varney
.....
....................
M.D.
Dee 29, 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.
In the
..... mos.
ds.
State ............ yrs.
mos.
.ds ............
......
Where was disease contracted, If not at place of death 7.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL St Patricks
DATE OF BURIAL
Dec 31
191
20 UNDERTAKER
O'Connell & Mack
ADDRESS
Gorhem 57
3 SEX
Mele
& DATE OF BIRTH
7 AGE
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
12 MAIDEN NAME
OF MOTHER
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
42
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) married
wht
MARGIN RESERVED FOR BINDING
1 PLACE OF DEATH Chetrez
Lome11
ford
(No. 146 Wrightman St St. :
57
......................... Ward)
Registered No.
82
....
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 linc is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- mon, (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 Doy laborer, Farm loborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- kcepers 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, ctc., of. ...... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; - Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, ctc. 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 violenec, 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 one supposed to be due 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.
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 Massarlutsetts
58
STANDARD CERTIFICATE OF DEATH
APLACE OF DEATH
Chelmsford
(No.
Elzen
Vmug
·
2 FULL NAME
[If married or divorced woman or kidow
give maiden name, also name of husband.]
@RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
- m
4 COLOR OR RACE
W.
$ SINGLE,
Marriedx
WIDOWED.
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
april (Month)
31
1827
7 AGE
40
... yrs.
8
mos.
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Mell operative
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Canada.
Contributory.
(SECONDARY)
.(Duration)
mos.
ds.
Showacht uma
M.D.
(Signed)
1917
(Address).
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
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)
16
Filed .. Dec. 31, 1917 Edward Y. Getting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
191 +
(Year
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was, as follows : -
Chowie baloular sonst science- It
-
No lundical actendances for - 5m
(Duration)
.. yrs.
.mos.
ds.
10 NAME OF FATHER
Jean Baptiste Prince
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Danada
12 MAIDEN NAME OF MOTHER queste Marie
13 BIRTHPLACE OF MOTHER (State or country)
Canada.
14 THE ABOVE IS TRUE TO THE BEST. OF MY KNOWLEDGE
DATE OF BURIAL
Jan 2. 1918.
20 UNDERTAKER
ADDRESS
Nat. Beladen 931 Merring
- St.
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
83
(Day)
... ,
(Year)
17
If LESS than
1 day .........
hrs.
....
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question 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 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 laborcr, 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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