USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 33
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lapse," " "Coma," "Convulsions,"" etc.), "Debility" ("Con- genital," "Senile, "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 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 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 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, 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. 100,000.
The Commonwealth of Massachusetts
Chelmsford 01
STANDARD CERTIFICATE OF DEATH
City or town)
1 PLACE OF DEATH
County.
Middleauf
State
mass
Registered No. 43
Township
or Village.
Courte chelmsford.
or
City:
No
St ...
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Daniel Proctor Ryan
(a) Residence.
No
Soute Chelmsford.
St.,
.Ward.
(Usual place of abode)
Length of residence in city or town wbere death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
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
6 DATE OF BIRTH (month, day, and year)
7 AGE Years
76
Months
6
Days
17
If LESS thao
I day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
Farmer.
particular kind of work.
(b) General oature of industry, business, or establishment io which employed (or employer) . (c) Name of employer
CONTRIBUTORY
(SECONDARY)
.(duration)
.. yrs.
.mos.
ds.
Did an operation precede death ?....
720
Was there an autopsy ?.
210
What test confirmed diagnosis ?
/26, 19/8 (Address)
Chelmsford Mass.
* State the DISEASE CAUSING DEATH, of An 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 Hout Pond Com.
DATE OF BURIAL May 282018
(Address)
15 Filed May 26, 1918 (Edward ), Rolfons
....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) May 25 1918
17
I HEREBY CERTIFY, That I attended deceased from
May 11
, 1918 to May 25
1918
that I last saw h/M alive on
May 25
1918.
and that death occurred, on the date stated above, at
10 P.m.
The CAUSE OF DEATH* was as follows:
arteriosclerosis
Surval
(duration)
.yrs ...
mos ..
ds.
9 BIRTHPLACE (city or town)
Chelmsford.
(State or country)
10 NAME OF FATHER
Marcus s. Byam
11 BIRTHPLACE OF FATHER (city or town)
Chelmsford
(State or country)
mars.
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
14
Informant
M. G. J. Puhleast (Languette
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 carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
MARGIN RESERVED FOR BINDING
PARENTS
18 Where was disease contracted
if not at place of death ?
X
Date of X
I.D.
12 MAIDEN NAME OF MOTHER
Mary Procla
5
/(Signed)
Umasa Stoward.
20 UNDERTAKER
ADDRESS
Walter Teskam Chelmsford.
(If non-resident give city or town and State)
REVISED UNITED STATES STANDARD CERTIFICATE OF !! ' [Approved by U. S. Census and American Public Health Association]
vommendations ~y Committee Medical Assu iation.) Under the provi- · deaths under the
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 dutics of the houschold only (not paid Housekeepers who reccive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Carc should be taken to report spe- cifically 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- catcd thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nonc.
Statement of cause of death .- Namc, first, the DISEASE CAUSING DEATHI (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cercbrospinal fever (thc only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (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; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (discase 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- lapse," "'Coma,' "Convulsions,"""Debility" ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," 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 de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - nomieide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
.
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 cliseasc, as A death upon the street, or mne 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.
-
1
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 Commmuralth of Massachusetts STANDARD CERTIFICATE OF DEATH
0.10% So Cheles Jard .... (City or town)
1 PLACE OF DEATH .
County.
Imiddlesex
State
massachusetts
Registered No. 11.4
Township
Chebusgard
.or Village.
or
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Luther 6. Totcomb
(a) Residence. No.
(Usual place of abode) Length of residence in city or town wbare death occurred 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)
Single
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
88
Months
3
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED Betired
(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) (State or country)
10 NAME OF FATHER Terrenciali Tetarul
11 BIRTHPLACE OF FATHER (city or town). (State or country)
12 MAIDEN NAME OF MOTHER Rebecca Pellebag
13 BIRTHPLACE OF MOTHER (city or town). (State or country) .
14
Informant
Rebecca Park
(Address)
15 Filed Jeme 7, 1918/60
REGISTRAR
16 DATE OF DEATH (month, day, and year) Summe 2
19 /F
17 I HEREBY CERTIFY May 14 1918
That I attended deceased from
.. , to ...
may 31, 19 18
that I last saw h M alive on ... May 31, 1918.
and that death occurred, on the date stated above, at . 1.0 ..... m.
The CAUSE OF DEATH* was as follows : Senile alterna
(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)
M.D.
6 1 , 19/ 8 (Address) Chelmsford, Brian,
* State the DISEASE CAUSING DEATH, of in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional spaec.)
19 PLACE OF BURIAL, CREMATION, OR REMOVED ong So Chelmsford 20 UNDERTAKER YoungBlake
DATE OF BURIAL Since 5 19
ADDRESS
Lowell.
ce
Webster
PARENTS
of certificate.
MARGIN RESERVED FOR BINDING
City
No ..
ford St.,
Ward.
(If non-resident give eity or town and State)
MEDICAL CERTIFICATE OF DEATH
1
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Preeise statement of oecupa- tion is very important, so that the relative healthfulnon- various pursuits ean be known. The question apples wo 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, Compos- itor, Architeet, Locomotive engineer, Civil engineer, Stationary fireman, ete. But in many cases, especially in industrial employments, it is neeessary 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 speeifieation, as Day laborer, Farm laborcr, Laborer - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid Housckeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At homc. Care should be taken to report spe- eifically the oeeupations of persons engaged in domestie serviee for wages, as Servant, Cook, Housemaid, ete. If the oeeupation has been changed or given up on aeeount of the DISEASE CAUSING DEATH, state occupation át beginning of illness. If retired from business, that faet may be indi- eated thus: Farmer (retircd, 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 respeet to time and eausation), using always the same aeeepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie eerebrospinal 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, 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- eurrent) affeetion need not be stated unless important. Example: Measles (disease eausing death), 29 &s .; 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," ete. 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 - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fraeture of skull, and consequences (e. g., scpsis, tetanus) may be stated
under the head of "fan de. " on statement of cause of des 1 . ou Nomens1 ,
Knowing conunions must be referred to the Medieal Examiners:
1. Deaths following injury or violenee, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
2. Deaths supposedly eaused 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 duc 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.
103
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City of town)
1 PLACE OF DEATH Meddled County
State
Bass
45 Registered No ...
.. or Village
Anth Chele fort
. or
St.,
Ward
(If death oeeurred in a hospital of institution, give its NAME instead of street and number)
Edward
(a) Residence. No ..
Middlece .
St.,
Ward.
(Usual place of abode)
Length of residence in city or lown where death occurred
years
months
days.
How long in U. S., if of forcign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
mala Hut
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
marked
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Julia Mason
6 DATE OF BIRTH (month, day, and year)
Years
7/
Months
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work.
Telied
(b) General nature of industry, business, or establishment in which employed (or employer) ... (c) Name of employer .
Canenter
9 BIRTHPLACE (eity or town).
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (clty or town)
(State or country)
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (elty or town)
/
(State or country)
14 Julia Venueaus Fils
(Address) Middlecy St Hof Otelicotone
15 Filed .. June 14 1918 Edward J. Rabbia
REGISTRAR ...
=
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) JAme 10- 1918
17 I HEREBY CERTIFY, That I attended deceased from parme 10 1918
, 19 ..
., to ...
1
that I last saw h ww
alive on
azúl
,1918
and that death occurred, on the date stated above, at
2300
.. m.
The CAUSE OF DEATH* was as follows :
€
(duration)
20
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 ?4
'&Signed)
14, 19/8 (Address) novos Chilinful.
I.I.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. (See reverse side for additional spaee.)
DATE OF BURIAL
19 PLACE OF BURIAL, CREMATION, OR REMOVAL europe , OR READThelunsford June 15 1918
20 UNDERTAKER
ADDRESS
MARGIN RESERVED FOR BINDING
2 FULL NAME 7 AGE PARENTS Informant 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 (State or country)
4 COLOR OR RACE
(If non-resident give city or town and State)
Township
City
No.
Beadlexx VII.
Cheles ford
......
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupatien. - Precise statement of occupa- tion is very important, so that the relative healthifulness 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 necdcd. 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- 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 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 fcver (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; 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 Gs .; 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," "Uremia," "Weakness," etc., when a definite discase 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 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 We head of "Contributory." (Recommen, !. ' on statement of cause of death approved by Con. on Nomenclature of the American Medical Associ
Cases for the Medical Examiners. - Under +1
sions of chapter 24 of the Revised Laws doat1.
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, ctc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or mne 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.
1917 1841 76
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,
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
104 No. 6 helmefords (City or towy)
1 PLACE OF DEATH
County.
Middlesex
State
Mark.
Registered No. 46
Township No. Chelmsford.
or Village ..
No Chelmsford
.or
Cottage Rour
St.,
Ward
(If death occurred in a hospital or institution, give its NAME Instead of street and number)
2 FULL NAME
Senas J. Stetson
(a) Residence. No
Cottage Row
St.,
Ward.
(Usual place of abode)
Length of residence in city or towo where death occurred
years
months
days.
How long in 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)
Single.
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
Oct1 2 9. 1841
7 AGE
Years
76
Months
7
Days
14
If LESS than 1 day, ........ hrs. or ........ mio. Chronic Melhores
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
Retired
(b) General nature of industry,
business, or establishment in
which employed (or employer) ...
(c) Name of employer
Retired.
9 BIRTHPLACE (city or town) ...
Lowell
(State or country) 16 ace.
PARENTS
10 NAME OF FATHER Sende Station.
11 BIRTHPLACE OF FATHER (city or town) .... Hancon .1. What test confirmed diagnosis ? 4
(State or country) Mass.
12 MAIDEN NAME OF MOTHER Martha Melvin
13 BIRTHPLACE OF MOTHER (city or town) Concord. (State or country) Marc.
14
Informant
George & steteon
(Address) No. Thelmaland Mass
15 a Sime 14, 1918 Edward Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
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