USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 36
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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, cte., of_
(namnc origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- eurrent) affection need not be stated unless important. Example: Measles (disease causing death), 29 &s .; 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,"' ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be aseertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, 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 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 the head of "Contributory." (Recommend on statement of cause of death approved by Correo on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths uuder the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violenee, 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, ete.
4. Deaths under circumstances unknown, as A person found dead, ete.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
R 15. 1-'18. 100,000.
L
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
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
PLACE OF DEATH Onlus ford, lunes. (No Crystal Lake
Cathrine
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
4 COLOR OR RACE
3 SEX Veck that,
6 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the word)
marked
6 DATE OF BIRTH
1889
(Month)
(Day) (Year)
If LESS than 1 day, ........ hrs.
yrs.
mos.
ds.
or ....... min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) ..
Hosted muy
9 BIRTHPLACE (State or country) Deland
10 NAME OF FATHER Samy Lins han
11 BIRTHPLACE OF FATHER (State or country)
Wieland
12 MAIDEN NAME OF MOTHER Mary Jelehan
13 BIRTHPLACE OF MOTHER (State or country)
Wieland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. Charles Carlson
(Address)
Inth Billewicy Maso
16 Filed ... July 22, 1918 Edward . Robbins REGISTRAR
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : Drowning accidental-
Sabina with duck water while walking along Shore of Count at nike- Drowned welche wich Lucbolig grone who man in der .
.(Duration)
.. yrs.
mos.
ds.
Contributory .. (SECONDARY)
Thomas Wwe ds.
.M.D.
191
(Address). MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR 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 poury S. Patins Carretera
DATE OF BURIAL July 2/ 19/8
20 UNDERTAKER
ADDRESS 324 Baufet ix
St.
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Seng A. tilson Registered No. 53
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
41 (Day)
191 (Year
....
-..
7 AGE 38
1
Catherine, Tunahan
Sister
Chele fond
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oceu- 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, Architeet, 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) Salcs- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer,","Forcman," "Manager," "Dealer," etc., without more precise specifieation, as Day laborer, Farm laborer, Laborcr - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid House- keepcrs 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, ete. 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 fact may be indicated thus: Farmer (rctired, 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 causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fcver (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. . definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The eontributory (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 disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or misearriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ete. 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 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."
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, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or onc supposed to be duc to Alcoholism, ete.
4. Deathis under circumstances unknown, as A person found dead, ete. . -.
R 16. 1-'17. 10,000.
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
A PLACE OF DEATH
(No.
Crystal Lake
Grace The Four
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Vnu ator n. No. Claimsto
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
1
(Month)
(Day)
191
......... ..
(Year,
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : prowamx-Weerdetal.
I Growadded an Effort to save love
who was also drowned w Crystal Lake).
.(Duration).
........... yrs.
.mos.
ds.
Contributory. (SECONDARY)
(Duration)}
Lyrs.
mos. ds.
1 howar vion .. , M.D.
(Signed)
(Address).
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
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 ?.
Former or usual residence
BURIAL OR REMOVAL Your4 I. Patur, Quete
DATE OF BURIAL July 24/1998
4
ADDRESS 324 Bauset sy.
SEX mals
4 COLOR OR RACE
Mit
5 SINGLE
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
maurer
G DATE OF BIRTH
1 (Month)
(Day)
6 1876
(Year)
7 AGE
If LESS than 1 day ......... hrs.
42
yrs. .....
... mos.
1 mos. 1 5ª
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).
9 BIRTHPLACE
(State or country)
Stort Covington 1.4.
10 NAME OF FATHER Vilas Th Halen
PARENTS
11 BIRTHPLACE OF FATHER (State or country} Brazier Hallo 1.4.
12 MAIDEN NAME OF MOTHER
Earl
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Vila M. Milan Brother (Informant) ....
(Address)
1 Jagranit St.
15 July 22, 1918 Edmond & Robbins REGISTRAR
Chelux
/114
(City or town . ) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St.
Ward)
Registered No.
54
20 UNDERTAKER
dinner
2
STANDARD CERTIFICATE OF D.
Statement of occupation. - Precise statement of oecu- 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 engincer, 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, 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 home. Care should be taken to report specifically the occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Cercbro-spinal fever (the only definite synonym is "Epidemic 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, perito ... im, etc .. ". 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 (sccondary), 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; Poisoncd by carbolic 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 "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 Examincrs:
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- posurc, etc.
3. Sudden deathis 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, ete.
R 16. 1.'17. 10,000.
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,
:
(City or fown)
1 PLACE OF DEATH
County ...
Township City
No.
St.
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Still Jan Barlow
2 FULL NAME
(a) Residence.
No ..
(Usual place of abode)
Length of resideoce in city or town where death occurred
years
Nordling & Pheles
w St. ,
Ward.
How long in U. S., if of foreign hirth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
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)
July 25.1918
7 AGE
Years
Months
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kiod of work
-
(b) General nature of industry. business, or establishment in which employed (or employer). (c) Name of employer
9 BIRTHPLACE (city or town).
Cheledord
(State or country) mako
10 NAME OF FATHER Trening Paulo
PARENTS
11 BIRTHPLACE OF FATHER (city or town) Helena (State or country)
12 MAIDEN NAME OF MOTHER Margaux Melty 1/2/1918 (Address)
13 BIRTHPLACE OF MOTHER (city or town) Chatham (State or country)
14 Swing Ballon gather
Informant
(Address) Chelunsford mars
15 July 20, 1918 Edward Spelling REGISTRAR
16 DATE OF DEATH (month, day, and year) July 25 1918
17 HEREBY CERTIFY, That ! attended deceased from July 2.5, 1918, July 25, 1918
that I last saw h. ... alive on 19
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.
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?
(Sigoed)
Autorit Scobanca
.,
M.D.
Clubenford, mars.
* 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.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL LA Pating. Country Poury July7/2018
20 UNDERTAKER'
ADDRESS 324 May et Ex
of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
State Marx
Registered No. 55
or Village .. Chelmsford .or
(If non-resident give city or town and State)
months
days.
MEDICAL CERTIFICATE OF DEATH
€
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Hoyhe' "
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to cach 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, espceially in industrial cinployments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and thereforc an additional linc is provided for the latter statement; it should be used only when needed. As cxamples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Forcman, (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 specification, as Day laborer, Farm laborer, Laborer -Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- eifically the occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATII, 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 (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- fed, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, ete., of_
(name origin; "Cancer" is less definite; avoid usc of "Tumor" for malignant ncoplasms); Measles; Whooping cough; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 &s .; Broncho- pneumonia (secondary), 10 ds. Never report mcre symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" (“ Con-
genital," "Senile," cte.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Urcmia," "Weakness," etc., when a definite disease can be ascertaincd as the eausc. 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 hcad - homicide; Poisoned by carbolic 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 "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenelature of the American Medical Association.)
Cases for the Medical Examiners. - Un' ~ the provi- sions of chapter 24 of the Revised Lav"
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, Exposurc, etc.
3. Sudden deaths of persons not disabled by recognized discasc, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under eireumstanees unknown, as A person found dead, ete.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
.
R 15. 1-'18. 100,000.
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
14 Steffen N. Jegles etather
Informant . (Address) Jyvasbord Road Forth Cheles Long
15 Filed. any 13, 1918 Edward, Robbin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) aug. 13, 1918
17 I HEREBY CERTIFY, That I attended deceased from Ony 18, 1918, to ang 12 1918
that I last saw h &M alive on
aug 12 2018
and that death occurred, on the date stated above, at
...
The CAUSE OF DEATH* was as follows :
Malnutrition
quetiv anterete,
(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 ?.. e
(Sigoed)
Claro (Adres) 1918 Chatons 200
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state'(1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
I. Paturj. Cemetery
DATE OF BURIAL Towel Cung 13 2018
20 UNDERTAKER
ADDRESS
James et O Donnell Non 324 Harsett
11,4
The Commonwealth of Massachusetts
Chelui ford
STANDARD CERTIFICATE OF DEATH
(Cky or towni)
1 PLACE OF DEATH
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