USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 24
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.......... yrs.
.mos.
.......
Where was disease contracted, if not at place of death ?.
Former or usual residence ..
DATE OF BURIAL
19 PLACE OF BURIAL OR REMOVAL IN Patrick'sC Kan 281918
DO UNDERTAKER
ADDRESS 171 acken
4 COLOR OR RACE
W.
5 SINGLE,
MARRIED . Widowed!
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Dan
27.1918
(Month)
(Day)
(Year,
MEDICAL CERTIFICATE OF DEATH
66
......
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 caclı and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Former or Planter, Physician, Compositor, Architect, Loco- motive enginecr, 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 specification, as Day laborer, Farm laborcr, Laborer - Coal mine, etc. Women at home, who are engaged in the dutics 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 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 .... .... (namo origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affcetion need not be stated unless im- portant. Example: Mcasles (discase 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," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite disease can be ascertaincd 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 deathis 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.
The Commonwealth of Massachusetts
6% Lowell. (City or town)
STANDARD CERTIFICATE OF DEATH
......
Registered No. 1259 .......
Township
City Lowell
....... or Village ..
No Lowell Corp, Hospital St, 2
or
Ward
(If death occurred in a hospital or institution, give its NAME Instead of street and number)
2 FULL NAME
George
.............
St.,
Ward.
chelmsford mass
(a) Residence.
No.
(Usual place of abode)
Leogtb of resideoce in city or town wbere death occorred
years
months
days. How long io U. S., if of foreigo birth ?
(If non-resident give eftf or town and State)
Wears
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
male white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
G DATE OF BIRTH (month, day, and year)und 157 8571
7 AGE
Years
Months
"Days
If LESS tbao 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Farmer
(b) General nature of industry, business, or establishment in wbich employed (or employer) . (c) Name of employer
9 BIRTHPLACE (eity or town).
Unknown
(State or country)
10 NAME OF FATHER
Charles E. Perry
11 BIRTHPLACE OF FATHER (city or town). (State or country) Sherborn mass
12 MAIDEN NAME OF MOTHER Jugan Garvin
13 BIRTHPLACE OF MOTHER (eity or town) Cane (State or country) new Hampshire
cord
14
Informant . mrs Eigene maraton
(Address) mp
15
Filed Jan. 31. 1 6 18.12.12
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year )January 282018.
17 I HEREBY CERTIFY, (That I attended deceased from november 15, 1917, to January 28, 1918.
28 2018.
that I last saw him alive on
-
2.35
and that death occurred, on the date stated above, at
.......
.... m.
The CAUSE OF DEATH* was as follows :
Endocarditis
(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 ?
Clark
(Signed)
M.D.
1-28 19 18 (Address) (Lowell Corp. Hoop
* 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.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Pripy Rid
Cemetery Chelmsford mais
20 UNDERTAKER
J. a. weinbeck
DATE OF BURIAL Jan 31 19 18. ADDRESS Lowell
MARGIN RESERVED FOR BINDING
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. 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,
1 PLACE OF DEATH
County middlesex
State massachusetts
of certificate.
PARENTS
99
12
UNITED <> TS STANDARD CERTIFICATE OF DEATH "nd American Public Health Association)
Statement of secup .... Precise statement of occupa- tion 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, Compos- itor, Architect, Locomotive 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 necded. 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 - 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, Houscwork, 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 (rctired, 6 yrs.). For persons who have no occupation whatever, write None.
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; Bronchopncumonia ("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 ncoplasms); 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," "Hcmorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," ctc., 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 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 un statement of cause of death approved by Committec on Nomenclature of the American Medical Association.)
Gases for tho Medical Examiners. - Under the provi- sions of chapter 21 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 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.
1
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX in 7 AGE PARENTS (informant) important. See instructions on back of certificate. N B - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ....
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Chelmo Sandonato corham St. : Ward)
68
...... ..
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
? FULL NAME Still Born ( Lagran)
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE chelmsford man
Registered No.
10
MEDICAL CERTIFICATE OF DEATH
I L
8.
(Month)
(Day)
(Year,
· DATE OF BIRTH
(Month)
(Day)
1
(Year)
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) Chelmsford man.
10 NAME OF FATHER taxeph gagnon
11 BIRTHPLACE OF FATHER (State or country) Danada
12 MAIDEN NAME OF MOTHER Agnesterian
18 BIRTHPLACE OF MOTHER (State or country)
10 anada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)
Chelmsford mes
16 Filed. Sam. 31, 1918 Edmond Fikations
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased trom
.....
191
....... , to
...
191
......... .
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 : Still born
(Duration) ..
............... yrs. ............
.mos.
.........
ds.
Contributory (SECONDARY)
.... yrs.
.mos. ds.
(Signed)
Lam 3D, 1918 (Address). 813 merema
* 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.
mcs.
ds.
State ...
........... yrs.
...
In the
mos.
....... .... ds ............
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Hl Joseph's C
DATE OF BURIAL
tel. 2, 198
20 UNDERTAKER
albert
ADDRESS
171 Gucken
MARGIN RESERVED FOR BINDING
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
20
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH zan 31. 191
neues
M.D.
S
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 caclı 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, ete. Women at home, who are engaged in the dutics 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, ete. 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 oecu- 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 cercbro-spinal meningitis"); , Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, is indefinitc) ; Tuber .
1
1
1
1
-
culosis of lungs, meninges, peritonaeum, 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; Chronie interstitial nephritis, etc. Tho contributory (sccond- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (discasc causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mcre symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "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 deathis 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 strect, 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.
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
t
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Marth The Surface
Hammer
„St. ;
Ward)
(City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
the
4 COLOR OR RACE
6 SINGLE-
MARRIED,
WIDOWED,
OP DIVORCED
( White the word)
DATE OF BIRTH
don't havewar
1800
(Year)
(Month)
(Day)
7 AGE
If LESS than
{ day ......... hrs.
ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
House work
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Gamada
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Canada
12 MAIDEN NAME
OF MOTHER
0
Jamie Parace
12 BIRTHPLACE
OF MOTHER
(State or country)
Grinada;
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
, (Informant) ....
Husband
(Address)
Nath thefunkand
15 Del. 7 .1918 Edward Je Robbins
REGISTRAR
16 DATE OF DEATH
-
(Month)
(Day)
1918 (Yeaf,
.......... ...............
I HEREBY CERTIFY that I attended deceased trom
Samy 29, 1918, to
July 6
1918
..... that I last saw h ~ alive on ............. , 1918 and that death occurred, on the date stated above, at 7 ......... G ....! m. The CAUSE OF DEATH* was as follows :
(Duration)
.......
... yrs.
mos.
dz.
Contributory
(SECONDARY)
(Duration)
Fund Warey
........... yrs.
.. mos.
ds.
..........
(Signed)
July 6
1915 (Address).
n-Chelmsford
...
M.D.
(* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
.... yrs.
.... mos.
.ds.
State ...
... yrs.
mos.
ds .....
Where was disease contracted, If not at place of death ?
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL St Joseph
DATE OF BURIAL
Fel 8.
1918
20 UNDERTAKER A fechambault Mirmah
ADDRESS
738
Filed
.....
Marie Lau
que
Marie Laure allard Henry Herron
Registered No.
MEDICAL CERTIFICATE OF DEATH
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Darth Gluhusband
69
in the
......
10 NAME OF
FATHER
abraham allard
........ 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 naturc of the business or industry, and therefore an additional linc is provided for the latter statement; it should be used only when nceded. 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," 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- kecpers who receive a definite salary), may be entered as Housewife, Houscwork, or At home, and children, not gain- fully employed, as At school or At homc. 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 (retircd, 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 timc and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fcvcr (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. (name origin: "Caneer" is less definite; avoid use of "Tumor" for malignant ncoplasms); Mcasles; Whooping cough; Chronic valvular hcart discase; Chronic interstitial nephritis, etc. Tho contributory (second- ary or intercurrent) affection necd not bo stated unless im- portant. Example: Mcasles (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," "Senilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage,". "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease ean be aseertained as the eause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL scpticaemia," "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- posurc, 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.
3 SEX male 7 AGE PARENTS (Informant) 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 Commomuralth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
4 hely e ford
(No
)
William G. Hout
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Mich He Cheln ford
PERSONAL AND STATISTICAL PARTICULARS
6 SINGLE,
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