USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 29
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51
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-
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) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. 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" (mcrely 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 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.
1
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.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 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
1 PLACE OF DEATH
.. (No Billenca Road
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Cedoviram Howard
2 FULL NAME.
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chilunfard mars
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE
while
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
Och 12 -1834
(Month)
(Day)
- (Year)
7 AGE
83 V. 5
mos.
6
ds.
Or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Returid
............... ......
acute Cholangitis-
(Duration)
.. yrs.
mos.
de.
Contributory ...
(SECONDARY)
... (Duration).
.... yrs.
mos.
ds.
(Signed)
Autun 4, & Scolonia
M.D.
.,
Tu wach 18, 1918 (Address).
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
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 ...........
19 PLACE OF BURIAL OR REMOVAL Brucktore man
DATE OF BURIAL
Zar 21.
191.8
(Address)
16 Filed Mas. 20 1918 E brard X. Robbins
REGISTRAR
...
17
I HEREBY CERTIFY that I attended deceased trom
March 5
1918
March18, 1918
to
If LESS than 1 day, ....... hrs. that I last saw h/ alive on. March 1, 1918 and that death occurred, on the date stated above, at .................. m. The CAUSE OF DEATH* was as follows :
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Bracktonmass
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Bruckto
12 MAIDEN NAME
OF MOTHER
Nor bucure
13 BIRTHPLACE
OF MOTHER
(State or country)
.
16 DATE OF DEATH
March
18
1918
(Year,
(Month)
Day)
.,
....
10 NAME OF
FATHER
Cyrus Howard
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
He. 14. Fraward
-
20 UNDERTAKER Houng& Blake
ADDRESS
Lauree
Chelmsford 85
Registered No.
27
........ yrs.
STANDARD
- itonaeum, etc., Carcinoma, Sar-
origin: "Cancer" is less
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) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer -- Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who 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 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 .
definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; 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 eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mcrcly symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage,", "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL 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.
-
1917- 63- 1854-5
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 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
I PLACE OF DEATH
(No
Newfield
St.
Ward)
No. 6 helms. (City ontown.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Registered No. 28
PERSONAL AND STATISTICAL PARTICULARS
& SEX
Female,
+ COLOR OR RACE
White
& SINGLE,
MARRIED
WIDOWED.
OR DIVORCED
(Write the word)
Widowed
$ DATE OF BIRTH
25 185.4
(Month)
(Day)
(Year)
7 AGE
63
.. yrs ..
mos. ........
9
ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Operative.
(b) General nature of industry,
business, or establishment In
which employed (or employer) ....
Operative.
9 BIRTHPLACE
(State or country)
Nova Scotia.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Nova Scotia
.
12 MAIDEN NAME
OF MOTHER
Unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
Nova Scotia.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Walter H. Nicklear
(Address)
Lowell, Moss Bulma, S&
16
Filed
ahr. It, 1918 Edward J. Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
April
(Month)
....
(Day)
191 21.
(Year)
17
I HEREBY CERTIFY that I attended deceased from
1912.
... , to.
.......... afet 2
......... , 1918 and that death occurred, on the date stated above, at 12,05m.
The CAUSE OF DEATH* was as follows : Cancer
of whims
Contributory
(SECONDARY)
..... (Duration).
............. yrs.
... mos.
................ ds.
y Ellarney
(Signed)
M.D.
azul 3 1912 (Address)
Notat Chilabi
* If death followed injury or violence the certificate of death must be made ont 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.
Where was disease contracted, if not at place of death ?
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Nestlawn Cemetery April 5, 1918
20 UNDERTAKER
grootealey
ADDRESS
79 Branch St.
€
. ........... ds.
.. (Duration)
9
............... yrs. .....
--. 7 ..... mos.
...
10 NAME OF
FATHER
Simeon Reid.
.
1
If LESS than [ day ....... ... hrs. that I last saw halive on.
86
AddieS. Nickles
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
No. Chelmsford.
Addie S. Reid. Stephen J. Ackles
.......
april 3
.1918
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 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) Salcs- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborcr," "Forcman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who 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 discase. 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," 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 ncoplasms) ; Mcasles; 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 discase can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," "PUERPERAL peritonitis," ctc. 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 discase, 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.
The Commomuralih of Massachusetts
STANDARD CERTIFICATE OF DEATH
.....
(City or town.)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
Mary Corcoran 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband. 2
Mary 7H & Sowell
David Registered No. 29
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED WIDOWED OR DIVORCED (Write the word)
1.
..
(Year)
If LESS than
ł day ......... hrs.
or ......... min. ?
9 BIRTHPLACE
(State or country)
Philadelphia
10 NAME OF
FATHER
I'm In! Dowell
11 BIRTHPLACE OF FATHER (State or country) Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Alias Corcoran
(Address)
Chichases Ind Metasil
16 Filed a/1. 5 .1918 Eduard Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Quail
4
(Month)
(Day)
191/2 (Year)
17 I HEREBY CERTIFY that I attended deceased from March 22. 191. to af 4, 1918
.......... ,
that I last saw h. alive on.
mel 30
191
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
(Duration)
... yrs.
.mos.
..............
.. ds
Contributory.
(SECONDARY)
......... (Duration))
............. yrs.
.. mos.
.ds.
(Signed)
......
M.D.
1918
(Address).
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
In the
.mr.os.
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 Jh Patricks
DATE OF BURIAL
apr. 7.
.... 191 8
........
....
.........
-
2U UNDERTAKER
ADDRESS
Lenall have
PLACE OF DEATH (No. @RESIDENCE 3 SEX COLOR ØR RACE · DATE OF BIRTH (Month) (Day) 7 AGE 64 ... & OCCUPATION (a) Trade, profession, or particular kind of work (b) General nature of industry, business, or establishment in which employed (or employer). 12 MAIDEN NAME OF MOTHER PARENTS 13 BIRTHPLACE OF MOTHER (State or country) ( Ireland. 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 ........ ............ yrs .. .mos. ds.
87
St.
......... Ward)
....
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean 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, 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) 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 preeisc specifieation, as Day laborer, Farm laborcr, Laborer - 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 ehildren, not gain- fully employed, as At school or At home. Care should be taken to report specifically the beeupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oeeu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the samc accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie 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, peritonacum, etc., Carcinoma, Sar- coma, ete., of. ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, ete. The contributory (second- ary or intereurrent) affection need not be stated unless im- portant. Example: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 .ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatie), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shoek," "Uraemia," "Weakness," ete., 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 eause for which surgieal 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, ete.
2. Deaths supposedly eaused by violenee, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ete.
4. Deaths under eireumstanees unknown, as A person found
*
dead, etc.
3
It rue
187/ m.
R. 15. 1-'17. 100,000.
(
1917 26
18910
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of busband.1
@RESIDENCE
No. Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Kale
៛ COLOR OR RACE
White
& SINGLE
MARRIED
Singles
WIDOWED.
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
June 21, 1891.
(Month)
(Day)
(Year)
AGE
If LESS than
1 day ........ hrs.
26 yrs.
9
„.mos.
25
.ds.
Or ........ min. ?
8 OCCUPATION
-
(a) Trade, profession, or
particular kind of work ...............*****
Painter.
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
Painters
9 BIRTHPLACE
(State or country)
Quincy, Mason
10 NAME OF
FATHER
George & Marinela
11 BIRTHPLACE
OF FATHER
(State or country)
England.
12 MAIDEN NAME
OF MOTHER
Sousa" Machow
PARENTS
13 BIRTHPLACE
OF MOTHER
Englands
(State or country)
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Geo. , Marinel,
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See Instructions on back of certificate.
(Address)
Nor Chelmsford
Filed
apr. 15, 1918 Edward ViRobbins
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
......
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
April
15%
., 1918
(Year)
/ (Month)
(Day)
17 I HEREBY CERTIFY that I attended deceased from april 9, 1918 to april 15 1918 ............ that I last saw alive on a Faut 15, 1918. and that death occurred, on the date stated above, at S A .m. The CAUSE OF DEATH* was as follows : Influenza
.. (Duration) ................ yrs.
-
.mos.
ds.
Contributory.
Chewing Endocarditis (aortic)
(SECONDARY)
(Duration) 3
.. yrs.
. ................ mos.
................
ds.
(Signed)
Daniel
defining
M.D.
april 15, 1910
(Address) 612 Sam Bloky Forell
......
* 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 ...
mos.
ds ......
Where was disease contracted, If not at place of death ?
Former cr usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Riverado ametery April 17, 1918.
20 UNDERTAKER
Groshatealay.
ADDRESS
79 Branches.
-
The Commwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
: PLACE OF DEATH no Chelmsford .. (No Groton Road. St.
Harrison I. Marinel.
89
No. 6 helman (City or-town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Ward)
............. .....
Registered No.
3/
.......
1
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 thereforc an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who reccive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.