USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 30
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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, 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, 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," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shoek," "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 septicacmia," "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
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
7 AGE PARENTS important. See instructions on back of certificate. N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ....
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
right
St. ......................... Ward)
[if death occurred In a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME James Edward Barker
[If married or divorced woman or widow give maiden name, also name of husband. 1 aRESIDENCE Straight DI. The Chuchusford Mass Registered No.
32
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Capril 2008
(Month)
(Day)
(Year)
@ DATE OF BIRTH
Man 10, 1886 (Montik
(Day)
(Year)
If LESS than 1 day ......... hrs.
31
yrs.
... mos.
/ ... ds.
Or ........ min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work ..............
(b) General nature of industry, business, or establishment which employed (or employer) .......
In Godten Mile
9 BIRTHPLACE (State or country) England
19 NAME OF FATHER Kalte Barbie
11 BIRTHPLACE OF FATHER (State or country) England
12 MAIDEN NAME OF MOTHER Dane Elingeworth
18 BIRTHPLACE OF MOTHER (State or country) England
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
ant) Materia Barbro
(Address) MrChelmsford Mas
16 Filed als 22 1918 Edward . Rol Fing
20 UNDERTAKER REGISTRARSEhunde
DATE OF BURIAL
Wewill Cemetery chil 22018
ADDRESS
217 APPLETON ST.
.mos ..
............... ds.
(Signed)
Fund EVarney
M.D.
april 20, 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
Hoch 90
.........
........
(City or town.)
....
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Male khite
+ COLOR OR RACE
5 SINGLE.
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
E Married
...
17 I HEREBY CERTIFY that I attended deceased from abril 8, 1918, to april 20 1918 ....... ...... that I last saw h alive on ........ . Einmal 201918. and that death occurred, on the date stated above, at 6am The CAUSE OF DEATH* was as follows :
Labas pneumonia -
(Duration)
yrs.
mos. /2 - ds.
Contributory ...
(SECONDARY)
..........
(Duration)
... 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 eases, 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, 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 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 oeeupation at beginning of illness. If retired from business, that faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affeetion with respect to time and eausation), using always the same accepted term for the same diseasc. Examples: Ccrebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinitc); Tubcr-
culosis of lungs, meninges, pcritonacum, etc., Carcinoma, Sar- coma, etc., of .. .......
...... (name origin: "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (sceond- ary or intercurrent) affeetion 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," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "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 eause 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, ete.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the strcet, or one supposed to be due to Alcoholism, ete
4. Deaths under cireumstanees unknown, as A person found dead, ete.
N.
R. 15. 1-'17. 100,000.
275 ADDRESS - orham
0 John L. Moronough
0 1
H
REGISTRAR
Filed anr. 23
91
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County Middlesex
State Mass
Registered No. ...
33
Township
Chelmsford Centre
.. or Village.
.... or
No.
Westdord St
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME.
Mary A. Fullerton
(a) Residence.
No.
Chesimsford Centre
St.,
.Ward.
(Usual place of abode)
Length of residence in city or town where death occurred 1 O
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) widowed
5a If married, widowed, or divorced HUSBAND of (or) WIFE of John Fullerton
6 DATE OF BIRTH (month, day, and year)
Months
Days
If LESS than
I day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
At home
. (duration)
2
4
.mos ............ .
. ds.
CONTRIBUTORY
Cardiac Analysis
(SECONDARY)
(duration)
...... yrs ...
.mos ...
4ds.
18 Where was disease contracted
if not at place of death?
X
Did an operation precede death ?
no. Date of
x
Was there an autopsy ?.
no.
What test confirmed diagnosis ?.
observation of symptom
LP (Signed)
masa toward.
., J.D.
1/23, 19/8 (Address) Chelmsford Mars.
* 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.)
14 Thomas McDonough
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
St. patrick's
DATE OF BURIAL
Apr. 24,18
(Address)
Westford St. chelmsford
File apr. 23 1918 Edward J. Bobbing REGISTRAR
20 UNDERTAKER
John L. Mcronough
ADDRESS
176 ~ornam
MARGIN RESERVED FOR BINDING
City. 3 SEX female 7 AGE Years 56 particular kind of work .. PARENTS Informant 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. 15 N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (b) General nature of industry, business, or establishment in which employed (or employer) .. (c) Name of employer
9 BIRTHPLACE (city or town)
(State or country)
Lowell
Mass
10 NAME OF FATHER
Thomas McDonough
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Ireland
12 MAIDEN NAME OF MOTHER Mary Watson
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Ireland
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) april 21 19/8
17
I HEREBY CERTIFY, That I attended deceased from
Jan
1916, to
apr. 21 st.
. 19.18.
apr. 10.The.
that I last saw her alive on
, 1918
and that death occurred, on the date stated above, at 12 2care
The CAUSE OF DEATH* was as follows :
Progressive muscular atrophy
.. yrs .........
(If non-resident give city or town and State)
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATHI [Approved by U. S. Census and American Public Health Association]
Statement of occupation. -- Preeise statement of oeeupa- tion 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 oceupations 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, ete. But in many eases, 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," ete., without more precise specifieation, as Day laborer, Farm laborcr, Laborer -Coal mine, ete. 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- eifieally the oeeupations of persons engaged in domestie serviee for wages, as Scrvant, Cook, Housemaid, ete. It the oeeupation has been changed or given up on aeeount of the DISEASE CAUSING DEATH, state oeeupation at beginning of illness. If retired from business, that fact may be indi- eated thus: Farmer (retired, 6 yrs.). For persons who have no oeeupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affeetion with respect to time and eausation), 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 fcver (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, ete., Carcinoma, Sarcoma, ete., of.
(name origin; "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The eontributory (secondary or inter- current) affeetion need not be stated unless important. Example: Mcasles (disease eausing death), 29 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "Col- lapse," 'Coma," "Convulsions," "Debility" ("Con- genital," "Senile,"
ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shoek," "Uremia," "Weakness," ete., when a definite disease ean be aseertained as the eause. Always qualify all diseases resulting from ehild- birth or misearriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State eause 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- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - nomicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fraeture 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 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 violenee, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, 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, ete.
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 important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
IPLACE OF DEATH
Chelmo ford, wars. No micato Se vto. Chalutier
St. Ward)
audrain Dzie du losse
[If married or divorced woman or widow give maiden name, also name of husband.] 0 @RESIDENCE 539 Forkaw Ha howell. 2010.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED WIDOWED OR DIVORCES ME (Write the word)
(Month)
(Day) (Year)
If LESS than I day ......... hrs.
29
yrs. .
- mos.
- ds.
or ........ min. ?
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE (State or country) " Lethuance
Andreeis Aquedulonis
11 BIRTHPLACE OF FATHER (State or country)
Lithuania
12 MAIDEN NAME OF MOTHER Use Sobomate
13 BIRTHPLACE OF MOTHER (State or country) Lethuanca
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Addres )3 Tterhaceto
16 d. apr. 26, 1918 Edward & Rotting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
april rt
(Month)
(Day)
98 (Year,
17 1 HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
Facture of face ofily Mail.
Harduza
(Traveling un automobiles which left road way and
(Duration)
ds
mos.
Contributory .. (SECONDARY)
(Duration)
yrs ....
1
mos.
ds
(Signed)
Vhoward Huis.
april , 1918 (Address)
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES. state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL 01 HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OF RECENT RESIDENTS).
In the
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
DATE OF BURIAL Chat 28/1918
ADDRESS
10 UNDERTAKER
92
(City or town.) -
fif death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME 3 SEX - 6 DATE OF BIRTH 7 AGE 8 OCCUPATION 10 NAME OF FATHER PARENTS 1 CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very (a) Trade, profession, or particular kind of work ... (Informant)
18881
Registered No. 34
.. yrs.
M.D.
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 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 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- kecpers 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 .(name origin: "Cancer" is less definite; avoid use of "Tuinor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced 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. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine 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."
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 onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R 16. 1.'17. 10,000.
-
The Commonwealth of Massachusetts
93 Prahansford
STANDARD CERTIFICATE OF DEATH
(City or toyu)
1 PLACE OF DEATH '
County.
Township Chelmsford
City
No ...
.or Village ... Woodline
St.,.
.........
... Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME.
(a) Residence. No.
(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
3 SEX
damals.
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED Qwrite the word)
Linde
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
66
Years
Months
Days
If LESS than
1 day, ........ hrs.
or .......
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
9 BIRTHPLACE (city or/town) .. 9
(State or country)
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city or) town).
(State or country) Laland
12 MAIDEN NAME OF MOTHER Jun Janner
13 BIRTHPLACE OF MOTHER (city or town) .. (State or country) Dvora Seria
14 Margaret Heaany
Informant (Address)
15
Filed. apr. 26 1918 Edward & Robbing
REGISTRAR
16 DATE OF DEATH (month, day, and year) apr. 24 1918
17 I HEREBY CERTIFY, That I attended deceased from Cinq 15, 1917, to
/ atrice
that I last saw h 3
alive on
19 ..
and that death occurred, on the date stated above, at 10
...... m. The CAUSE OF DEATH* was as follows :
.(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 ?
200 Date of.
Was there an autopsy ?.
What test confirmed diagnosis ?
(Signed) ,19 ( Address)
M.D.
* State the DISEASE CAUSING DEATHI, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, aud (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
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