USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 35
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genital,"
"Senile,"
etc.),
"Dropsy,"
"Exhaustion,"
-
'Heart failure," " Hemorrhage," "Uremia," "'Weakness," "Inanition," "Maras- mus," "Old age," "Shock," etc., when a definite disease can be ascertained as the eause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. 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 - nomicide; Poisoned by carbolic acid -- probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Casas 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, ete.
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.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS
BY
PHYSICIAN.
1
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,
of certificate.
14
Informant
Martin IT, Conley Suht.
1
(Address) 6 ha ima ford ST. Hochithe
15 July 6, 1918 Edward &. Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
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) 1869.
7 AGE 4.9
Years
Months
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kiod of work. Weaver.
(b) General nature of indostry, business, or establishment in which employed (or employer) . (c) Name of employer
Gro. b. Moore Nicol Scouring Mill.
Grange B. Moore
9 BIRTHPLACE (city or town).
England.
(State or country)
10 NAME OF FATHER Jesore Slatford.
PARENTS
11 BIRTHPLACE OF FATHER (city or town) Omg Land. (State or country)
12 MAIDEN NAME OF MOTHER Anna Bennett,
13 BIRTHPLACE OF MOTHER (city or town) England (State or country)
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 ?. Ford Elhamer
(Signed)
294 1918 (Address) Novot Chelmsford Maar
M.D.
* State the DISEASE CAUSING DEATH, or iu deaths from VIOLENT CAUSES, state (I) 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 Edson Cemetery.
DATE OF BURIAL July 8, 1918.
ADDRESS 19 Branch les
The Commomuralth of Massachusetts STANDARD CERTIFICATE OF DEATH
108 No. Chelmsford. (City er town)
1 PLACE OF DEATH
County ..
.State
Mace
.Registered No. 50
Township City No
.... or Village.
No. Chelmsford
Adamai
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME.
John Slatford
(a) Residence.
No
Adame
St., ...
Ward.
(Usual place of abode)
Length of resideoce in city or towo where death occurred
years
months
days.
How long in U. S., if of foreigo birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH (month, day, and year)
July 6
19/8
17 I HEREBY CERTIFY, That I attended deceased from 1918, to buy 6 .. ,
that I last saw h 4 alive on
19/8
530 a
and that death occurred, on the date stated above, at .
......
m.
The CAUSE OF DEATH* was as follows :
sudden death
.(duration) ... yrs ..
-
.mos .... ds.
CONTRIBUTORY
acula direclety
(SECONDARY)
(duration)
3
yrs ...
.mos ...
ds.
MARGIN RESERVED FOR BINDING
...........
.or
(If non-resident give city or town and State)
20 UNDERTAKER
FromReally
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation, - Precise sta' wat of occupa- tion is very important, so that the relative new .'niness of various pursuits can be known. The question appHAVE 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, ctc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Groecry; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Forcman," "Manager," "Dealer," ctc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the houschold only (not paid Housekeepers who reecive a definite salary), may be entcred 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 affcetion with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (thc only definite synonym is "Epidemie 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 usc of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronie 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- lapse," ." "Coma," "Convulsions," "Debility" ("Con- genital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. 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 (c. g., sepsis, tetanus) may be stated
under the head of "Contribr . .. fi te . + of cause of 1
intion.)
VUI.
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.
Pq 38 Come and to Book
DECEDENT
The Commonwealth of Massachusetts AFFIDAVIT AND CORRECTION OF DEATH REGISTRY OF VITAL RECORDS AND STATISTICS
#79 #108
91-1
DEPOSITION NO.
STATE USE ONLY
DECEDENT - NAME
FIRST
MIDDLE
LAST
Allen
SEX
N F
DATE OF DEATH (Mo., Day, Yr.)
3 August 18, 1918
HOSPITAL OR OTHER INSTITUTION - Name (If not in either, give street and number)
4c
91 South Main Street, Reading, MA
PLACE OF DEATH (Check only one):
HOSPITAL:
Inpatient
ER/Outpatient DOA
OTHER:
Nursing Home
Residence
Other (Specify)
5
WAS DECEDENT OF HISPANIC ORIGIN?
(If yes, Specify Puerto Rican, Dominican, Cuban, etc.)
NO
RACE (a.g. White, Black, American Indian, etc.)
(Specify):
8b
White
DECEDENT'S EDUCATION (Highest Grade Complated)
Elem/Sec (0-12) | College (1-4, 5 +)
AGE - Last Birthday
(Yrs.)
UNDER 1 YEAR
MOS
DAYS
UNDER 1 DAY HOURS , MINS -
C
10c
-
11
Huberston, MA
MARRIED, NEVER MARRIED
WIDOWED OR DIVORCED
Never Marr.
13
RESIDENCE - NO. & ST., CITY/TOWN, COUNTY, STATE/COUNTRY
(off) Park Road Chelmsford, MA Middlesex
15a
ZIP CODE
15b
-
FATHER - FULL NAME
16 John Allen
STATE OF BIRTH (If not in US,
name country)
17
MA
18
Unknown
STATE OF BIRTH (If not in US,
name country)
19
Unknown
RELATIONSHIP
22
--
METHOD OF DISPOSITION
ÅBURIAL
FUNERAL SERVICE LICENSEE
.
--
25
--
PLACE OF DISPOSITION (Neme of Cemetery, Cremetory or other)
26a
Forefathers Cemetery
LOCATION (City/Town, Stata)
26b
Chelmsford, MA
DATE OF DISPOSITION
(Mo., Dey, Yr.)
27
Aug. 21,1918
NAME AND ADDRESS OF FACILITY
28a/b
Young & Blake
Lowell, MA
29 PART I - Enler the diseases, injuries, or complicalions that caused the deeth. Do not use only the mode of dying, such as cardiac or respiratory errest, shock or heart failure. List only one cause on each line (e through d). PRINT OR TYPE LEGIBLY.
IMMEDIATE CAUSE (Final
disease or condition resulting
in death)
e
Carcinoma of bowels & liver
DUE TO (OR AS A CONSEQUENCE OF)
Sequentially list conditions, If any leeding to immediate cause. Enter UNDERLYING CAUSE (disease or injury that initiated events resulting in death) LAST.
b
DUE TO (OR AS A CONSEQUENCE OF)
C.
DUE TO (OR AS A CONSEQUENCE OF)
d
PART II - Other signficiant conditions contributing to death but not resulting In underlying cause given In Part I.
30
WAS CASE REFERRED 34 MANNER OF DEATH
TO M.E .?
(Yes or No)
--
NATURAL
ACCIDENT
HOMICIDE SUICIDE
COULD NOT BE DETERMINED
PENDING INVESTIGATION
--
DATE OF INJURY
(Mo., Cay, Yr.)
35a
TIME OF INJURY
31
INJURY AT WORK
(T'es or ivo)
M
35c
DESCRIBE HOW INJURY OCCURRED
LOCATION (No. & St., City/Town, State)
35d
DATE SIGNED (Mo., Dey, Yr.)
HOUR OF DEATH
DATE SIGNED (Mo., Dey, Yr.)
HOUR OF DEATH 37b M
PRONOUNCED DEAD (Hr.)
LICENSE NO. OF CERTIFIER 37d M
NAME AND ADDRESS OF CERTIFYING PHYSICIAN OR MEDICAL EXAMINER (Type or Print)
38 George F. Dow
20 Woburn Street, Reading, MA
WAS THERE AN R.N. PRONOUNCEMENT? Yes or No 40€
IF YES, DATE
PRONOUNCED
-
IF YES, TIME
PRONOUNCED
40d NAME OF PRONOUNCING REGISTERED NURSE
NAME
41 DEPONENT - NAME AND ADDRESS Charlotte P. DeWolf
12 Park Place Chelmsford, MA
41a DATE OF ORIGINAL RECORD
Sept. 3, 1918
42 RECEIVED IN
CITY OR TOWN OF
Reading
Catherine a. Quimby
(CLERK'S SIGNATURE)
AUG 2 9 1991 (DATE OF RECORD)
R-306-89
INFORMANT
DISPOSITION
- Mary
PLACE OF DEATH (City/Town)
4a
Reading
COUNTY OF DEATH
Middlesex
4b
SOCIAL SECURITY NUMBER
IF US WAR VETERAN
SPECIFY WAR
--
7
9
BIRTHPLACE (City and State or Foreign Country)
10a
80
b
LAST SPOUSE (If wife, give meiden name)
USUAL OCCUPATION
(Prior - If retired)
14a
AT Home
14b
--
MAILING ADDRESS - NO. & ST., CITY/TOWN, STATE, ZIP CODE
INFORMANT'S NAME
Howard L. Park
21
Reading, MA
LICENSE
23
ENTOMBMENT
DONATION
OTH. SPEC:
CREMATION
REMOVAL FROM STATE
24
Approximate Interval
Between Onset and Death
3 mos.
To be Completed by
CERTIFYING PHYSICIAN ,
-
-
36a
36b 5:45 AM
≥37a
Only
NAME OF ATTENDING PHYSICIAN IF NOT CERTIFIER
36c
37c
WAS AUTOPSY
PERFORMED?
(Yas or No)
No
WERE AUTOPSY FINDINGS AVAILABLE PRIOR TO COMPLETION OF CAUSE OF DEATH? (Yes or No) 32 No
PLACE OF INJURY - At home, ferm, street, factory, office bldg., etc. Specify: 35€ -
35
To Be Completed by
MEDICAL EXAMINER
OPRONOUNCED DEAD (Mo., Day. Yr.)
39 --
40b
40c --
M
MOTHER - NAME
(GIVEN)
(MAIDEN)
KIND OF BUSINESS OR INDUSTRY
12
CERTIFIER
BLACK INK ONLY
20
YES
8a Specify:
DATE OF BIRTH (Mo., Day, Yr.)
6
REGISTERED NUMBER
35b
AFFIDAVIT
ALL ADDITIONS AND CORRECTIONS MUST BE SUBSTANTIATED BY WRITTEN EVIDENCE (M.G.L. CHAP. 46 SECTION 13)
TYPE WITH PERMANENT BLACK INK. THIS IS A PERMANENT RECORD.
The undersigned, being duly sworn, depose and say, under penalties of perjury, that the record relating to the death of Mary Allen
(Give name of decedent exactly as recorded on the original record)
in the community of Reading
(Name of city or town)
does not fully and/or correctly state all the facts regarding:
XXDecedent * Item(s) # 15A
Informant * Item(s) #
Disposition *Item(s) #
Certifier * Item(s) #
Other
*Indicate item #'s as they appear on the reverse of this form
DEPONENT NAME Charlotte Poloog
RESIDENCE 15 Park Place Chelmsford, MA
RELATION TO DECEDENT
Great Aunt
FURTHER, the written evidence made at or near the time of the death submitted to substantiate the affidavit was:
Certificate of residence received in Town Clerk's Office from the Town of Chelmsford Dated July 23, 1991
THEN Personally appeared before me the person(s) whose signature(s) appear(s) above and made oath that the statements subscribed are true.
Date: August 27, 1991
Name:
7-11-97
(Month, Day, Year)
Chelmsford
Official Designation:
Ass't Town Clerk, Notary
(City or town clerk, assistant clerk, registrar, or notary)
CATHERINE A. QUIMBY TOWN CLERK
A TRUE COPY, ATTEST: Catherine a. Quimby
CITY AND TOWN CLERKS MUST TRANSMIT A COPY OF THIS RETURN TO THE COMMISSIONER OF PUBLIC HEALTH AT ONCE.
109
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
...........
(City or town) .
1 PLACE OF DEATH)
County ..
Andificil
State ...
mars
Township
or Village ...
....... or
St.
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
meth Raoul Rondeau
(a) Residence. No.
.....
(Usual place of abode)
Length of residence in city or town where death occurred
years
montbs
days.
How long in U. S., if of foreign birtb ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED. WIDOWED, OR
DIVORCED (write the word)
Finale
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
Months
March 2619 and that death occurred, on
Days
If LESS than
1 day, ........ hrs.
or ........ min.
... Il. The CAUSE OF DEATH* was as follows : Cholera Infantino
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work.
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
CONTRIBUTORY
(SECONDARY)
(duration)
... yrs ...
.mos ...
ds.
18 Where was disease contracted
if not at place of death ?.
.
Did an operation precede death ?
Date of
10 NAME OF FATHER George Kondens Was there an aut
11 BIRTHPLACE OF FATHER (city or town) While flex what test confirmed diagnosis ?
(State or country)
Not Signed) Lubochelto
MI.D.
12 MAIDEN NAME OF MOTHER 01020 serie 23 6,198 (Address) 732 Merrimack
13 BIRTHPLACE OF MOTHER (city or town) Sulle (State or country)
* State the DISEASE CAUSING DEATII, 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
Informant 5/1/2011
(Address)
15 Filed July 6, 1918 Edward Y Rotting REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR REMOVAL It Bach
DATE OF BURIAL July 7 5 19/
ADDRESS 738
20 UNDERTAKER At chanribaud
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.
PARENTS
.(duration)
.yrs ..
mos ...
ds.
9 BIRTHPLACE (city or town) ......
(State or country)
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and ycar)
July 6
1918
17 I HEREBY CERTIFY, That I attended deceased from July 1 , 1918 to July 6
that I last saw hele alive on
1918
(If non-resident give city or town and State)
Registered No. 51
City Hohe Siufand No. 69
REVIS"
.. TIFICATE OF DEATH s l'ubije Health Association]
se statement of occupa-
tion is very important. hat the relative healthfulness ~~ various pursuits can ve 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, Architcet, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many eascs, 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," 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. 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- eatcd thus: Farmer (rctired, 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 eontributory (secondary or inter- eurrent) affection need not be stated unless important. Example: Measles (disease eausing death), 29 Gs .; Broncho- pncumonia (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," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," e." "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Strvek by railway train - accident; Revolver wound of hcad - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." enendations on statement of cause of death ar Cominittce on Nomenelature of the America .ociation.)
Cases for the Medical Examiners. · provi-
sions of chapter 24 of the Revised Laws
iviiowing 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 circumstanees unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTIIER 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 ternis,
of certificate.
14
Informant
Asa HI naarth
(Address)
Chalnaturel Les
15 Filed., July 20, 1918 Edward J. Bobbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Temale
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
Months
Days
10
If LESS than
1 day, ........ hrs.
or ........ min.
Locomotor ataxia
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
At Home
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.
9 BIRTHPLACE (city or town) Son ~~~ 1
(State or country)
..
10 NAME OF FATHER Tedon Death
PARENTS
11 BIRTHPLACE OF FATHER (city or town) Spre [vill
(State or country)
mire
12 MAIDEN NAME OF MOTHER " Spooner
13 BIRTHPLACE OF MOTHER (city or town) Sangerville (State or country) Tainn
18 Where was disease contracted
if not at place of death?
Did an operation precede death?
No - Dat
.. Date Of.
Was there an autopsy ?
no
-
What test confirmed diagnosis ? Clinical Symptoms,
Test. Vou Deursen.
M.D.
(Signed)
July 1918 (Adress) 20 Palmer St. Lowell Maso
* State the DISEASE CAUSING DEATH, or ju 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
Sapparville
Maine
DATE OF BURIAL July 2219/8
20 UNDERTAKER Young & Plake
110
The Commmuraith of Massachusetts STANDARD CERTIFICATE OF DEATH
Chela for:
(City or town)
1 PLACE OF DEATH
County .............. 5 x
State ... Massachusetts
Registered No. 52
Township
or Village.
.or
City
No.
St ...
......
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Enelia D. Dearth
(a) Residence. No .....
St.,
Ward.
(If non-resident give city or town and State )
(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
16 DATE OF DEATH (month, day, and year) .
19/8
17 I HEREBY CERTIFY, That I attended deceased from Oct 6 1917, to July 19 1918
that I last saw her
... alive on
may 28th
, 19/8
and that death occurred, on the date stated above, at60 P
.. m.
The CAUSE OF DEATH* was as follows :
MARGIN RESERVED FOR BINDING
ADDRESS
Lowell
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Preeise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applics to . each and every person, irrespective of age. For many occupations a single word or term on the first linc will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive 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) 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 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- eifically 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no oeeupation whatever, write None.
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