USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 28
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years
months
days.
How long in U. S., if of foreign birth ? years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX male
4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) White Single
5a If married, widowed, or divorced HUSBAND of (01) WIFE of
6 DATE OF BIRTH (month, day, and year) (Oct. 28, 1913
7 AGE
Years
Months
Days
4
4
10
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
(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)
Clark
M.D.
3-11 19/11 (Address) owell Corpittogo.
* 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. (Sce reverse side for additional spacc.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
hel
mass
mar. 1/ 2018.
toreph
wetery
20 UNDERTAKER
a archambault 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,
of certificate.
14
Father
Informant
no. Chelmsford
(Address)
15
Filed ... mar. 131918.12
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) march 10 1918.
17 I HEREBY CERTIFY, That I attended deceased from march 10, 1918, to march 10, 1918
that I last saw him alive on
...
10, 1918.
and that death occurred, on the date stated above, at 9.40 yo, m. The CAUSE OF DEATH* was as follows:
If LESS than 1 day, ........ hrs. or ........ min. Laryngeal Diphtheria
9 BIRTHPLACE (city or town) ... ] n) no. Chelmsford
(State or country)
mark. 1
10 NAME OF FATHER
alfred
PARENTS
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
Canada
12 MAIDEN NAME OF MOTHER dwidge dureatt
13 BIRTHPLACE OF MOTHER (city or town) .. (State or country) Canada
Sowell 81
or
(If non-resident give city or town and State)
e
8
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 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 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- eifically 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, statc 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 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- mus," "Old age," "Shock," "Uremnia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or iniscarriage, 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 carbolie 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.)
Casos 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, ctc.
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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City of town)
1 PLACE OF DEATH, ,
County. Miales
Township Chelmsford
or Village. Center
.or
City
No ..
Boston Rd
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Edith Way Parkhurst
(a) Residence. No ... Usoston Rd.
St.,
Ward.
(Usual place of abode)
Length of residence in city nr town wbare death occurred
years
mnaths
days.
How Inng in U. S., if nf foreign hirth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 70
4 COLOR OR RACE w
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) Married
5a If married, widowed, or divorced HUSBAND of (or) WIFE of of Edgar Of Tarkhet
6 DATE OF BIRTH (month, day, and year)
Left. 20. 1869
7 AGE
Years 48
Months 5
Days 19
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, professinn, nr particular kind of work
at home
(b) General nature nf industry, business, or establishment in which employed (or emplnyer) (c) Name of employer
9 BIRTHPLACE (city or town).
(State or country)
O NAME OF FATHER nadora Bosca
Was there an autopsy ?.
What test confirmed diagnosis ? Arthur G. Scoboria,
(Signed) .
[.I.D.
, 1318 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.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Pine Ridge Com.
DATE OF BURIAL Man. 14/ 1918
(Address) chelmsford
15
Filed Mar, 14 19 8 Gaward & Rolling REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) March II 19
I8.
17 I HEREBY CERTIFY, That I attended deceased from March 5. , 19 ..... „, to .. March JI .19. I8
that I last saw jer
alive on
March II
191 8.
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows :
Acute Lobar Pneumonia.
4
(duration)
yrs ... .mos. ds.
CONTRIBUTORY (SECONDARY)
„(duration)
... yrs ..
mos.
ds.
18 Where was disease contracted if not at place of death ?
well mars.
PARENTS
11 BIRTHPLACE OF FATHER (city or town). (State or country) Canada
12 MAIDEN NAME OF MOTHER delicie Willett
13 BIRTHPLACE OF MOTHER (city or town) Ilattebrugt (State or country) N.Y. 0
14
Informant Edgar 7. Park Jueves
20 UNDERTAKER ADDRESS Walter Perham Chelmsford
MARGIN RESERVED FOR BINDING
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, N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
chequefund 82
State. Mars .
Registered No. 24
(If non-resident give city or town and State)
5 P.M.
Did an operation precede death? Date of.
....
ne
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[ Approved by U. S. Census and American Public Health Association]
Statement of occupati. " e statement of oceupa- 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., Former or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stotionory fireman, ete. 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) Salesmon, (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 loborer, Farm loborer, 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 spc- cifically the occupations of persons engaged in domestic serviee 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- eated 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 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 ncoplasms); Measles; Whooping cough; Chronic volvulortheart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 Gs .; Broneho- pneumonia (secondary), 10 ds. Never report mere symp-
toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col-
"Convulsions,"" "Debility" (“ Con- lapse," "Coma,"
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shoek," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from ehild- birth or misearriage, 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 roilway 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 eause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chanter 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, ete.
2. Deaths supposedly caused by violence, as Criminal obortion, 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 cireumstanees unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
*
R 15. 1-'18. 100,000.
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,
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
83
WORCESTER
(City or town)
1 PLACE OF DEATH
County ...
WORCESTER,
State.
MASS
Registered No. 25
Township
City ..
WORCESTER
No ..
.or Village. Worcester State Hospital
St ..
......
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Charles F Patterson
St.,
.Ward.
Chelmsford
(If non-resident give city or town and State)
(Usual place of abodc)
Length of residence io city or towo where death occurred
-
years
1
mooths
23 3lays.
How long io U. S., if of foreign birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Elizabeth F Moore
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
Months
Days
If LESS thao I day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
General Paralysis of the insane
(a) Trade, profession, or
Printer
particular kind of work.
(b) Geoeral nature of industry, business, or establishment io which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
Lowell
(State or country)
10 NAME OF FATHER
Charles
11 BIRTHPLACE OF FATHER (city or town).
(Statc or country)
N.H.
12 MAIDEN NAME OF MOTHER Sara Noyes
13 BIRTHPLACE OF MOTHER (city or town) (State or country)
- N.H.
14
Informant
Hospital records
(Address)
Worcester /
15
Filed ... Mar-1819 ,19
18
REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Lowell Cem. Lowell
DATE OF BURIAL
Mar 161918
20 UNDERTAKER
Callahan Bros.
ADDRESS
WORCESTER,
of certificate.
PARENTS
18 Where was disease contracted
if not at place of death ?
unknown
Did an operation precede death ?
no Date of
Was there an autopsy ?.
no
What test confirmed diagnosis? laboratory & cline
(Sigoed) ....... JamesTAdams
ical . M.D.
.. , 19
(Address)
Worcester
* 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.)
(duration)
5
.yrs ........ wn ..
1
.. mos ...
CONTRIBUTORY (SECONDARY)
„.(duration)
.........
yrs ...........
... mos ..
.ds.
.......
17 I HEREBY CERTIFY, That I attended deceased from
Jan
22
19.18 ...
Mar
14
. 19
18
that I last saw h .... ].Il alive on
Mar 13 , 19 18
and that death occurred, on the date stated above, at 8 A
.. m.
The CAUSE OF DEATH* was as follows :
MARGIN RESERVED FOR BINDING
53
16 DATE OF DEATH (month, day, and year)
Mar 14
19 18
MEDICAL CERTIFICATE OF DEATH
(a) Residence. No.
Middlesex
.. or
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Associa# ... .
Statement of occupation. - Precise statement of oecupa- 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, Architeet, 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," "Dcaler," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the dutics 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, cte. 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.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respcet to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie 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 ncoplasms); Measles; Whooping cough; Chronie 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 (sceondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con-
genital," "Scnile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shock," "Uremia," "Wcakness," etc., when a definite disease can be ascertaincd 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 dc- terniine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by earbolie 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, ete.
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.
4
The Ommmmmmmmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH I PLACE OF DEATH
St.
Ward)
....
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 26
.......
fond.
Registered No.
26
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
Mariel
1
· DATE OF BIRTH
(Month) (Day)
1
(Year)
7 AGE
If LESS than [ day ......... hrs.
55
2
.mos.
16
ds.
....... yrs.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work
Norman 73 +M.R.
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Sammank.
10 NAME OF
FATHER
?
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
?
12 MAIDEN NAME
OF MOTHER
3
13 BIRTHPLACE OF MOTHER (State or country)
2
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
1
(Address)
Chelmsford.
16 File mar, 16, 1918 Estrand S. Robban
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Mich.
-
1918
(Year)
(Month)
.
(Day)
17
I HEREBY CERTIFY that I attended deceased from
1917 to Mak 15
8
191.
that I last saw h ~ alive on 1918 and that death occurred, on the date stated above, at 7 3 ...... m. The CAUSE OF DEATH* was as follows :
Diabetes
Known que (Duration).
July 1917 -
mos.
ds.
Contributory ..
(SECONDARY)
(Duration)
............ yrs.
.. mos. ds.
M.D.
(Signed)
Mich16
918
(Address) JudSarney
* 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.
yrs.
.. ds ........ ......... .... Where was disease contracted, If not at place of death ?.
Former er usual residence
19.PLACE OF BURIAL OR REMOVAL Kalena, Marine.
DATE OF BURIAL Man 19. 1918
20 UNDERTAKER Humana @ groupe
ADDRESS 345 Matferd S.
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
MARGIN RESERVED FOR BINDING
Important. See instructions on back of certificate.
84 ·
(City or town.)
Send(No
[if death occurred in a hospital or institution, give its NAME Instead of street and number.]
... mos.
....
.....
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- motivc enginecr, 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," "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 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 domestie 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 occu- pation whatever, write None.
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