USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 23
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Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, 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 (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as " Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" (“Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the eause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to dc- termine 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 (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committec on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following 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 violenee, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, 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.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18.
10,000.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH lehetnsford (No. Bartlett
St. :
...........
Ward)
Eval Jannie Webster
[If married or divorced woman or widow give maiden name, also name of husband. Cevat: Lemonde- Winfried Webster. @RESIDENCE
Registered No. 5
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH Jan 15
(Month)
(Day)
1918. (Year)
17
I HEREBY CERTIFY that I attended deceased from
Jan"
13 192
, to Hai 14. 1918
that I last saw her alive on ...
Jan
14
... 1918.
and that death occurred, on the date stated above, at 6:30am,
The CAUSE OF DEATH* was as follows :
Right 7th migliaia
Probably Cerebral Harmonhoge.
1
(Duration)
... yrs.
mos.
ds.
Contributory ..
(SECONDARY)
39 hours.
-2 (Duration) ...
......
yrs ....
.mos. ds.
(Signed)
Fiche S. celona
M.D.,
Van 16
1919 (Address) Cluboford M
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
yrs.
mos.
ds.
State ...
............ yrs.
In the
mos.
ds ...
....
Where was disease contracted,
If not at place of death ?. .... usual residence .. Former or
1 PLACE OF BURIAL OR REMOVAL mapleur d'lene. antrin N. H
DATE OF BURIAL
Jan. 18.
1918
1%
Filed
Jan. 16 08 Edward Mobbing
REGISTRAR .....
,63
.......
(Cityor town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
$ SINGLE
MARRIED
WIDOWED.
OF DIVORCED
· DATE OF BIRTH
May
14 1866
(Month)
(Day)
AGE
.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
at home
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Aritrino N. H.
11 BIRTHPLACE/
OF FATHER
(State or country).
" Autrice N. H
12 MAIDEN NAME
OF MOTHER
Phoebe a, Kelsea
PARENTS
13 BIRTHPLACE
OF MOTHER
State
try) Lisbon N. H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. ER. Clark (sister)
important. See instructions on back of certificate.
(Address) Chelmsford mais,
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
51
yrs.
8
mos.
ds.
or ........ min. ?
If LESS than 1 day, ........ hrs.
(Year)
10 NAME OF
FATHER
Ephrians Simmonds
...........
Q UNDERTAKER
Walter Terhanc
ADDRESS
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precisc 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 engincer, 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 inaterial 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, Laborcr - Coal mine, etc. Women at home, who arc 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, Houscmaid, 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"); Diphthcria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tubcr .
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. .......................... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart 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," "Scnile," etc ), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
.......
7. Letelier
St. :
Ward)
Caroline
Soplica adams
Otis Adana
Registered No.
6
PERSONAL AND STATISTICAL PARTICULARS
Widow
12 1829
(Year)
If LESS than { day ......... hrs.
...... ds.
or ........ min. ?
at home
9 BIRTHPLACE
(State or country)
Weetford Mais
10 NAME OF
FATHER
Jack Glover
11 BIRTHPLACE
OF FATHER
(State or country)
Dedkam Mass
12 MAIDEN NAME
OF MOTHER
Nancy Hilduch
13 BIRTHPLACE
OF MOTHER
(State or country)
Weekend Mars
14 THE ABOVE IS TRUE TO THE REST OF MY KNOWLEDGE
(Informant)
Mrs. a. S. Reed (daughter)
(Address)
Filed_ Jan. 18, 1918 Edward. Robban
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jan. 18
(Month)
(Day)
1918
(Year)
17 I HEREBY CERTIFY that I attended deceased from Jan. 4 , 1918, to Jan, 18, 1918
that I last saw hey alive on
Jan 18, 198
and that death occurred, on the date stated above, at 6 G.m.
The CAUSE OF DEATH* was as follows :
Carcinoma of colon
unknown
... (Duration)
............. yrs.
mos.
ds.
Contributory .............
(SECONDARY)
(Duration)
.... yrs.
mos.
ds.
(Signed)
Amara Howard
M.D.
Jan. 21.
.......
1918 (Address).
Chelonsford Mass.
(* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
... yrs.
mos.
In the
ds.
State ....
............ yrs.
mos.
ds.
Where was disease contracted, if not at place of death ?.
Former or usual residence .. ......
DATE OF BURIAL
8
19 PLACE OF BURIAL OR REMOVAL Foutathus Cen.
Chelenstand, Mass Jans 21, 191
20 UNDERTAKER
Waller Perbam
VADDRESS
Chelmsford
1 PLACE OF DEATH Chelmsford (No. 2FULL NAME 3 SEX 7 4 4 COLOR OR RACE Tilute 5 SINGLE MARRIED WIROWE! OR DIY · DATE OF BIRTH 0 " AGE 89 8 OCCUPATION (a) Trade, profession, or particular kind of work (b) General nature of industry, business, or establishment in which employed (or employer) .. PARENTS CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ........ ..... ......... yrs .. 0 mos. 6
........
(City or town.) Tif death occurred in a hospital or institution, give its NAME instead of street and number.]
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE chelmsford.
Lau.
(Month)
(Day)
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 eaeh 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 cxamples: (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 specifieation, as Day laborer, Farm laborer, Laborer - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid Housc- 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 oceupation 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 affeetion 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 eerebro-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, ete. The contributory (seeond- ary or intercurrent) affection need not be stated unless in- 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," "Shoek," "Uraemia," "Weakness," etc., when a definite disease ean be ascertained as the eause. Always qualify all diseases resulting from childbirth or misearriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ete. State causc 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 eonditions must be referred to the Medical Examiners:
1. Deaths following injury or violenee, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
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
1 PLACE OF DEATH !
County.
middlesex
(a) Residence.
No.
(Usual place of abode)
Length of residence in city or town where death occurred
years
4 COLOR OR RACE
témale white
6 DATE OF BIRTH (month, day, and year)
Months
Days
60
8 OCCUPATION OF DECEASED
10 NAME OF FATHER
"1
11 BIRTHPLACE OF FATHER (eity or town)
(State or country)
12 MAIDEN NAME OF MOTHER
"
13 BIRTHPLACE OF MOTHER (eity or town) ..
(State or country)
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
particular kind of work.
at Home
14 mrs.m & Gulline
(Address) - middles ex It
15 Filed aw. 22 1918 9
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
January 19 1918.
17 I HEREBY CERTIFY, That I attended deceased from
as
mary -
1918, to January 19, 2018.
that I last saw
be alive on
/19 19 18.
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
If LESS than
1 day, ........ hrs.
or ........ min.
Carcinoma of Intestines
(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 ?..
(Signed).
arthur & Scoloria
.. , M.D.
1-21, 1918.(Address)
Chelmsford moved
* 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 spaee.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
Westlawn Cemetery Jan 22 19 18
20 UNDERTAKER H.a. simmons
ADDRESS Lowell.
Township 3 SEX 7 AGE Years (a) Trade, profession, or PARENTS Informant carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, of certificate. N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
The Commonwealth of Massachusetts
Lowell
STANDARD CERTIFICATE OF DEATH
(City or town)
State Massachusetts
Registered No .....
City.
Lowell
No.
Village ... St. John's Hospital
.or
St.
.. Ward
(If death ofeurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Fanny w ho
y n'hompsos
St.,
.....
.. Ward.
Chelmsford et, mais.
months
days.
How long in U. S., if of foreign hirth ?
(If non-resident give dity or town and State) months ) years
days
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) Widowed
5a If married widowed, or divorced HUSBAND of widow of Leonard Thompson
9 BIRTHPLACE (city or town). (State or country) Unknown
REVISED UNITED STATES STANDA. .. CERTIFICATE OF DEATH [Approved by U. S. Census and America ra : . alth Association]
Statement of occupation. - Precise statement tion is very important, so that the relative health.
various pursuits can be known. The question apples tu 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, Compos- itor, Architect, Locomotive 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) 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," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Cool 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 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nonc.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (thc only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcomo, 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 (secondary or inter- current) affection need not be stated unless important. Example: Mcosles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Dcbility" ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by corbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomencla. ~ `nan Medical Association.)
Cases for tho * - Under the provi- sions of chapter 24 v. deaths under the following conditions must ve reierrea to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gos poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, 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.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 10,000.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
3 SEX 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 ...
1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH West Chelmas ford
St. : Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
? FULL NAME Philomena Di Palma merci
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE W. Chelmsford.
Philomena de Lucia- michael de Palma
Registered No. 8
PERSONAL AND STATISTICAL PARTICULARS
· DATE OF BIRTH -
(Month)
(Day)
1
(Year)
If LESS than
1 day ......... hrs.
64
... yrs. mos. ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work ......................********
.
home
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Italy
10 NAME OF
FATHER
Pascal di Lucia.
11 BIRTHPLACE
OF FATHER
(State or country)
Italy
12 MAIDEN NAME
OF MOTHER
francisca
18 BIRTHPLACE
OF MOTHER
(State or country)
Italy.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
mr. De Calmo.
(Address)
W. Chilme food
Filed Jan. 27, 198 Edward X, Patbry REGISTRAR
17
I HEREBY CERTIFY that I attended deceased trom
Dans
/1918, to
May 27, 1918
that I last saw h/ ~ alive on
Jay 21, 1918
and that death occurred, on the date stated above, at 700 m.
The CAUSE OF DEATH* was as follows :
Organic diecan ) head,
(Duration) .
1
... yrs.
mos.
ds.
Contributory.
(SECONDARY)
.(Duration) .
........... yrs.
..........
... mos.
... ds.
............
(Signed)
Fred Elane
M.D.
Rey. 28, 1918 (Addre
M. Chilequal
* 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 piace
of death.
.. yrs.
.mos.
ds.
State.
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