USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 22
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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, peritonacum, etc., Carcinoma, Sar- coma, etc., of. .(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; 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 (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. 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., scpsis 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
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 strect, or one 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.
3 SEX 7 AGE PARENTS important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ...
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
No. Chelmsford (No. 11
Gay
St.
............... Ward)
Tlf death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
Female. White
5 SINGLE.
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single.
$ DATE OF BIRTH
Oct.
21
1917
(Month)
(Day)
(Year)
Or ......... mln. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work.
None.
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
None
9 BIRTHPLACE
(State or country)
No. Chelme, Mace.
10 NAME OF
FATHER
Am. H. Williame.
11 BIRTHPLACE
OF FATHER
(State or country)
England.
12 MAIDEN NAME
OF MOTHER
Lilly Ir hitter.
18 BIRTHPLACE
OF MOTHER
(State or country) England.
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
m. H. Williams.
(Address) No. Chelme. Mace.
16 Filed San 3, 198 Edward Y. Robbins
REGISTRAR
...
(Month)
(Day)
19188
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Dec 28 1917, to.
Jan 3
1918
...
If LESS than I day ........ ........ hrs. that I last saw him alive on
1918
and that death occurred, on the date stated above, at 8 /
8A.m.
The CAUSE OF DEATH* was as follows :
Brancho- preussena
.(Duration)
.......
.... yrs.
...
.mos. ....
7
ds.
Contributory ..
(SECONDARY)
......
.. (Duration)
.......
.. yrs.
................ mos.
ds.
(Signed)
Fred Elarney
M.D.
i ... San 3
. 1918 (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 ...
............. yTs.
.........
... mos.
.. ds ..
......
....
Where was disease contracted, If not at place of death ?.
Former or usual residence ..... ................................ ..............
6
19 PLACE OF BURIAL OR REMOVAL Riverside Cemetery.
DATE OF BURIAL
Jan. 5. 1918
....
Chelmsford.
20 UNDERTAKER Gro. Healey.
ADDRESS
79 Branch &g.
39 No. thelma (City ou town.)
Rose L. Williame
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband. aRESIDENCE 11 Gay 88.
16 DATE OF DEATH
Jan.
3.
.
v
. 2 mon
mos.
13
ds.
........ yrs ..
....... ....
......
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 bo 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 reccive 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) ; 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 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.
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
I PLACE OF DEATA
.(No
St. ....... ........... Ward)
8
Anne Poulson
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Registered No.
2
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
Female
· COLOR OR RACE
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
(Month)
(Day)
-
(Year)
7 AGE
10
.yrs.
6
.mos.
ds.
If LESS than
1 day ......... hrs.
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)
Handson n. M.,
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Jalan Mass.
12 MAIDEN NAME
OF MOTHER
Mary Anderegr.
13 BIRTHPLACE
OF MOTHER
(State or country)
Switzerland
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
John Sanlagen
(Address)
No. Chuchesford.
€
16 Filed. .....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
7
1918
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that ! attended deceased from
1918, to Day 7 1918 ... that I last saw ha alive on , ...... and that death occurred, on the date stated above, at 90 1 1918 m. The CAUSE OF DEATH* was as follows :
aculi delaben ? hat,
(Duration)
... yrs.
.. mos.
ds.
Contributory ..
(SECONDARY)
(Duration)
.......
... yrs.
.......
... mos.
10 ds.
(Signed)
Ford EVarney
M.D.
Domy. 8. 1915 (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.
in the
... mos.
ds ...
4 .....
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
JW. Chelmsford
DATE OF BURIAL
Low get 198
-
20 UNDERTAKER
ADDRESS
Down 345 Hereford is
60
... (City or town.)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
MARGIN RESERVED FOR BINDING
important. See instructions on back of certificate.
.
10 NAME OF
FATHER
John Paulvan.
bran.
da.
State
........... yrs.
...
I
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question 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 reccive 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 samc accepted term for the same disease. Examples: Ccrebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, 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 (sccond- 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Scnile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age,". "Shock," "Uraemia," "Wcakness," etc., when a definite discase can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
1
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15. 1-'17. 100,000.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
1 PLACE OF DEATH
(No.
....
2 FULL NAME
[If married or divoreed woman or widow
give maiden name, also name of busband]
@RESIDENCE
$ SEX
4 COLOR OR RACE
Made Villinte
(Day)
7 AGE
& OCCUPATION
(Farmer
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
11 BIRTHPLACE
. 0
OF FATHER
(State or country)
Chatknown
12 MAIDEN NAME
OF MOTHER
Sarah
PARENTS
18 BIRTHPLACE
OF MOTHER
(Mate or country) (Northern
(Informant)
Rua Banca
important. See instructions on back of certificate.
(Address)
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
....
66 yrs. 11 mos.
4
.ds.
5 SINGLE,
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
Massier
1
..... (Year)
If LESS than
! day ......... hrs.
or ........ min. ?
9 BIRTHPLACE
(State or country)
Harrie town Ny
10 NAME OF
FATHER
Lagarna Edwards
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
walterlednanon
15 Filed Jan, 9, 1918 Edward Y. Bobbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sau
1
(Month)
9
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Jan 1 5 , 1918 to than, 9
1918
that I last saw h wy alive on
Jan. 9
,
1918.
and that death occurred, on the date stated above, at 11:15am.
The CAUSE OF DEATH* was as follows :
acute Lobar incumonia.
.(Duration)
yrs.
...
... mos.
5
ds.
Contributory ..
(SLCONDARY)
(Duration).
.... yrs. ................ mos.
.. ds.
(Signed)
Low, 9, 1918 (Addres)
Cheland, Max:
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
13 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 7.
................................ Former or usual residence ....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
ADDRESS 20 UNDERTAKER VA embeek Lowell
61
The Commmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
St. : Ward)
Daring M Edwarde
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
3
PERSONAL AND STATISTICAL PARTICULARS
" DATE OF BIRTH
Hel- Sitt 1831
(Month)
1918
M.D.
STANDARD CERTOTUATE OF DEATH.
Statement of occupation. - Precise statement of oecu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to eaeli 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, ete. But in many cases, especially in industrial employments, it is nceessary 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 speeifieation, as Day laborer, Farm laborer, Laborer - Coal mine, 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 homc, 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 domestie serviee for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on aeeount of the DISEASE CAUSING DEATH, state oeeupation at beginning of illness. If retired from business, that faet may be indieated thus: Farmer (rctired, 6 yrs.). For persons who have no oceu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affeetion with respect to time and causation), using always the same accepted term for the same discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
1
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of .......
...... (name origin: "Cancer" is Icss definite; avoid use of "Tumor" for malignant neoplasms) ; Mcaslcs; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (seeond- ary or intereurrent) affection need not be stated unless im- portant. Example: Mcasles (disease eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., when a definite disease can be aseertained as the cause. Always qualify al. diseases resulting from childbirth or misearriage, as "PUER- PERAL septicacmia," "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 Medieal Examiners:
1. Deaths following injury or violenee, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly eaused by violenee, 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. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classifled. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
14 Father
Informant ......
(Address)
Chelmatory mass
15 Filed Jan. 22, 1918//
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year ) anuary 10 1918
17 I HEREBY CERTIFY, That I attended deceased from
,19
19.
to.
...
that I last saw h ............... alive on
,19.
........
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows:
Still Born.
(duration)
.. yrs ..
mos ..
.ds.
CONTRIBUTORY
(SECONDARY)
(duration)
... yrs ..
mos .........
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?.
Date of.
Was there an autopsy ?
What test confirmed diagnosis ?...
arthur G acabaria
(Signed)
1-20 19 18 (Address)
Chelmsford mass.
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
DATE OF BURIAL
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Forefathe
Chelmsford Mass. Jan. 21 1918
20 UNDERTAKER
Walter Perham
ADDRESS Chelmsford
The Commonwealth of Massarimusetta STANDARD CERTIFICATE OF DEATH
Lowell 62
(City or town) !"
1 PLACE OF DEATH
County middle
sex
Township .
City ..
Rowell
.. or Village ..
No. Lowell Gen. Hospital St. T.
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Still Born (Fisk)
(a) Residence.
No.
(Usual place of abode)
Leogth of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE !
Female White single
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year) January 101918.
7 AGE Years
Months
Days
C
If LESS than VI day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
(b) General nature of industry, business, or establishmeot io which employed (or employer). (c) Name of employer
9 BIRTHPLACE (city or town) ....
howell
(State or country} mais
10 NAME OF FATHER Lewis &
PARENTS
11 BIRTHPLACE OF FATHER (city or town) Billerica
(State or country) mass 12 MAIDEN NAME OF MOTHER Lottie E. allen
13 BIRTHPLACE OF MOTHER (city or town) howell (State or country) mass.
State Massachusetts Registered No
... or
....
Ward. Chelmsford mais
St.,
....
(If non-resident give city or town and State)
MARGIN RESERVED FOR BINDING
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupa- tion 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, Compos- itor, Architect, Locomotive engincer, Civil engineer, Stationary fireman, etc. But in many eases, 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "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 Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestie 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
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