USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 26
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The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
74
1 PLACE OF DEATH,
County ..
AMiddleaux
State.
There
Registered No. 16
.... or
City
No ..
St.,
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME.
Marie Niana Goberge
(a) Residence. No.
Chelimited MasSt.,
Ward.
(Usual place of abode)
Length 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
MEDICAL CERTIFICATE OF DEATH
3 SEX
V -
4 COLOR OR RACE
W-
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)
1917.
7 AGE
Years
-
Months
10
Days
If LESS than
1 day, ........ hrs.
or ........ min.
16 DATE OF DEATH (month, day, and year)
Ker. 18
1910
17
I HEREBY CERTIFY, That I attended deceased from
die 12
1918, to.
Fick 18
„, 1918
that I last saw h.LA ........ alive on
(, 1918
and that death occurred, on the date stated above, at
+319.
m.
The CAUSE OF DEATH* was as follows : Labella Pneumonia
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work ...
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
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)
Lukochelle
M.D.
1 2 18, 1918 (Address) 732 Masmuack
* State the DISEASE CAUSING DEATII, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL,
13 BIRTHPLACE OF MOTHER (city or town) It Maurice (State or country) Co. Champlain E. Q. CANA SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
14 Informant
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
In Joseph's
DATE OF BURIAL
Feb. 18 19/A
(Address)
15 File Feb. 18, 1918 Edward Hitting REGISTRAR
20 UNDERTAKER
ADDRESS
171 aiden
MARGIN RESERVED FOR BINDING
of certificate.
PARENTS
10 NAME OF FATHER
alfred Goberge
11 BIRTHPLACE OF FATHER (city or town) ..
chelmsford
(State or country)
12 MAIDEN NAME OF MOTHER Lucinda. ayotte
(duration)
... yrs .....
.mos ....
6 ds.
9 BIRTHPLACE (city or town)
Rowell
(State or country) maxu.
(City or town)
Township
chelimotout maso
.or Village.
(If non-resident give city or town and State)
Gril
REVISED UNITED STATES STANDARD CERI: - AE DEATH
[Approved by U. S. Census and Americor P W ;
Statement of occupation. - Preise statement . iCuil- tion is very important, so that the relative healthfulness of rious pursuits can be known. The question applies to each and every person, irrespective of age. For many oeeupations a single word or term on the first linc will be sufficient, c. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive cngincer, Civil engineer, Stationary fireman, ctc. 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) Salcsman, (b) Grocery; (a) Forcman, (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, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the houschold only (not paid Housekeepers wlio 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 spc- eifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. It 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.
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 diseasc. Examples: Cercbrospinal fevcr (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, ctc., 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- eurrent) affection necd not be stated unless important. Example: Measles (disease causing death), 29 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Ancmia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," ctc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. Statc cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably sueh, if impossible to de- terminc definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of hcad - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and conscquenees (c. g., sepsis, tetanus) may be stated
mler the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
ww. 3 for the Medical Examiners. - Under the provi- sions er chapter 24 of the Revised Laws deaths under the following condition_ __ st be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ctc.
2. Deaths supposedly caused by violenec, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ctc.
3. Sudden deaths of persons not disabled by recognized discase, as A death upon the street, or onc 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. 100,000.
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 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. Sharmaford. (NO
Middlerack
St.
Ward)
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband @RESIDENCE No. Chelmsford Mace.
PERSONAL AND STATISTICAL PARTICULARS
& SEX
Male.
4 COLOR OR RACE
& SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Midou
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
! 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)
Scout Marco.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Devend Mars.
12 MAIDEN NAME
OF MOTHER
2
1ª BIRTHPLACE
OF MOTHER
(State or country)
2
7
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Masson Quem.
(Address)
( Vr chelmsford.
15 Filed Feb 20 1918 Edward . Rolling
~REGISTRAR
...
(Month)
(Day)
.,
1918
(Year)
17 I HEREBY CERTIFY that I attended deceased from July 18 ...
, 1918 to.
1 July 20
1918
1
that I last saw h~ alive on
July 19
1918
...... ...... and that death occurred, on the date stated above, at /a. m. The CAUSE OF DEATH* was as follows :
Hemiplegia
.(Duration)
.. yrs.
mos.
ds.
Contributory ...
(SECONDARY)
(Duration).
.... yrs.
... mos. ...
ds.
(Signed)
Fred Varney
M.D.
July 20, 1918 (Address)
n. Chelmsford
...
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
ds.
In the
State ............ yrs.
mos.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death
... yrs.
mos. ....
Where was disease contracted, If not at place of death ?
Former cr usual residence
12 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Remisedo Comobino Culaire Det. 22- 1918
20 UNDERTAKER
ADDRESS
75
(City or town.)
[if death occurred In a hospital or institution, give its NAME instead of street and number.]
Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
20
91 yrs ..
1 mos. 5 ds.
.............. yrs. ........
important. See instructions on back of certificate.
10 NAME OF
FATHER
Theodor Hamblett.
.......
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," 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- 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 fevcr (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 aennite; 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," "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 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
1 PLACE OF DEATH,
County Middlesy
Township
City ..
howell
(a) Residence.
No.
(Usual place of abode)
Leogth of residence io city or town where death occurred
years
3 SEX
7 AGE
Years
Days
29
11
4
Months
11
8 OCCUPATION OF DECEASED
(a) Trade, professioo, or
(h) General nature of industry,
business, or establishmeot in
which employed (or employer) .
(c) Name of employer
9 BIRTHPLACE (city or town) howell
PARENTS
14
Informant
Husband
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
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
particular kiod of work.
at Home
(Address)
no. Chelmsford mass
15 Filed 2-257, 19 18/2-240000
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) ebruary 22 1918.
17 HEREBY CERTIFY, That I attended deceased from February 18, 1218 to February 22 2018
alive on
-
that I last saw ]
wer.
22. 2018
and that death occurred, on the date stated above, at
9.30 fr.m. The CAUSE OF DEATH* was as follows :
If LESS than 1 day ......... hrs. or ........ min. Surgical Shock following operation for appendicitis and hernia
(duration)
... yrs ...
mos.
2 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).
C
2-23, 19 18 6 dovresti ma
howell
ste
M.D.
* 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. (Sec reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
howell Cemetery
20 UNDERTAKER geo. W. Healey
DATE OF BURIAL 2 .2 57 1918
.
ADDRESS howell
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
forell (City or town) massachusetts Registered No. 18 State ..
.. or
....... or Village
No Lowell Gen. Hospital
St. 7
Ward
(If death occurred in a hospital or institution, give its NAHE instead of street and number)
2 FULL NAME
Jessica Re. moore
middlesex
St., .............
Ward.
no, Chelmsford mais
(If non-resident give city or town and State)
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
demald White married
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced J
HUSBAND of
(or) WIFE of
George P. moore for
6 DATE OF BIRTH (month, day, and year) Mar. 15/1888
(State or country) mario
10 NAME OF FATHER
I. Eugene Richardson
11 BIRTHPLACE OF FATHER (city (or town)) (State or country) massachusetts
12 MAIDEN NAME OF MOTHERCarrie nach
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
Massachusetts
months
days.
How loog in U. S., if of foreign birth ?
years
mooths
......
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
Approved by U. S. Census and American Public Health Association]
Statement of c - - Precise statement of occupa-
tion is very import: Vel 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 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 - Coal minc, etc. Women at home, who are engaged in the duties of the household only (not paid Housckecpers who receive a definite salary), may be entered as Housewife, Houscwork, or At home, and children, not gainfully employed, as At school or At homc. 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 (the only definite synonym is "Epidemic cercbrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fcvcr (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- ficd, 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 discase; 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," "Senilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "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 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 Committee on Nomenclature of the American Medical Association.)
Gases 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 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.
1917- 77~ 18400
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 Comunmuuralth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH No. 6 helmeford. (NO Tunstable Road St.
..................... .... Ward)
Mr. Chelone. (City or town.) [if death occurred In a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Melissa S. Bak Per
[If married or divorced woman or widow give maiden name, also name of husband.] Melissa S. Hucking. John N. Baker. 19 aRESIDENCE 24Ur Banton SX Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
23
(Day)
1918
(Year)
" DATE OF BIRTH
(Month)
0
(Day)
17
P
18:40
(Year)
Jan 25
1918 to Feby 23, 1918.
If LESS than
i day ......... hrs.
that I last saw her alive on Tedy
23, 1918
and that death occurred, on the date stated above, at 4:05m.
or ........ min. ?
The CAUSE OF DEATH* was as follows :
Cerebral Hommage
(a) Trade, profession, or
particular kind of work.
At Home,
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
At Home.
9 BIRTHPLACE
(State or country)
Wentworth, O. H.
10 NAME OF
FATHER
Nathan Huckine.
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
Sophia Kelley.
18 BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mine, Helen S. Burch.
(Address)
LowelliMaso
15 File tel 25, 1918 Edward& Raffin
REGISTRAR
.(Duration) ...
.......
.. yrs.
Mos. 208.
„ds.
Contributory
isentral Hafeitio
(SECONDARY)
dareal years
(Duration) ...
.......... yrs.
.mos.
.......
ds,
(Signed)
M.D.
Keby 25 1918 (Added) 612 Sam Alay Innell
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
in the
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death
yrs.
ds.
State ....
.yrs.
mos.
ds ..
Where was dlsease contracted, If not at place of death ?
Former cr usual residence.
19 PLACE OF BURIAL OR REMOVAL Edson Cem, Jomb.
DATE OF BURIAL
Feb, 27. 1918.
NU UNDERTAKER
GromoHealey,
ADDRESS
79 Branch Of,
AGE 8 OCCUPATION PARENTS CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ....
4 COLOR OR RACE
J SEX
Female White.
6 SINGLE,
MARRIED
Widoweds
OR DIVORCED
(Write the word)
77
... yrs.
7 mos 15
mos.
ds.
I HEREBY CERTIFY that I attended deceased from
.....
.... mos.
1
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- 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 oeeupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fircman, 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," "Forcman," "Manager," "Dealer," ete., without more precise specification, 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 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 serviee for wages, as Scrvant, Cook, Housemaid, etc. If the occupation has been changed or given up on aeeount of the DISEASE CAUSING DEATH, state oceupation at beginning of illness. If retired from business, that faet may be indieated thus: Farmer (retired, 6 yrs.). For persons who have no oeeu- pation whatever, write None.
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