USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 39
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City of town)
1 PLACE OF DEATH
County ..
huddlese
State
mars
Registered No ...
63
Township
C Colehumana 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
(a) Residence. No .. (Usual place of abode) Length of residence in city or town where death occorred years
montis
days.
llow 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)
5a If married, widowed, or divorced HUSBAND of (01) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Ycars
Months
78 4
2. Days 9h
-
If LESS than I day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work.
at Home
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town) ..
Canada
(State or country)
10 NAME OF FATHER dort Ramente
11 BIRTHPLACE OF FATHER (city or town) G dual What test confirmed diagnosis?
(State or country)
12 MAIDEN NAME OF MOTHER Bord Ramachic
13 BIRTHPLACE OF MOTHER (city or town) Canada (State or country)
14 Informant this & marchand
(Address)
15
Filed Sept. 23, 1918 Edward Rittern REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Lehet 20 1058
17
I HEREBY CERTIFY, That I attended deceased from Seth # 14 1918 to Sabah. 20 ., 1918.
that I last saw h w
alive on
Self. 14
1928.
okul 2578 on that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows :
Exterie Enteritis
(duration)
mos.
CONTRIBUTORY
arterio - Selensia
(SECONDARY)
several
(duration)
.yrs ...
.mos ..
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
no
Was there an autopsy ?
home
Kavaller
(Signed)
Soft 19 & (Address)
720 marinade a. donese
* 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
DATE OF BURIAL Jeff 23 1918
ADDRESS
738
20 UNDERTAKER A Tichambault Muswach
MARGIN RESERVED FOR BINDING
PARENTS
of certificate.
malloy
st, Ward.
(If non-resident give city or town and State)
12/
m.
feio
Date of. -
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
; American Public Health Association]
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 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, Architeet, 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 forin part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without inore 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 usc 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_
(naine origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie 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 ds .; 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 ascertained as the eause. 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 Committee Nomenclature of the American Medical Association.)
vases 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, Ilomieide, 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.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
12,2 No Chelmsford (City or town))
1 PLACE OF DEATH
County
middlesex
Township
North Chilinfand
.. or Village.
.... or
Ward (If death occurred in a hospital or institution, give its NAME instead of street and number) St., ......
2 FULL NAME
ameer a. Brauch
.....
(a) Residence. No .....
North Chelinefaid
St.,
.. Ward.
(Usual place of abode)
Length of resideoce in city or town where death occurred
years
Months
days.
How long in U. S., if of foreign birtb ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
01. 23
17
I HEREBY CERTIFY, That I attended deceased from
1/1-20
1918 to EH-23
1918
that I last saw h 4
alive
......
22
19 48
and that death occurred, on the date stated above, at ......
......... 1 a ........... m. The CAUSE OF DEATH* was as follows :
.(duration)
3
yrs.
mos ..........
ds.
CONTRIBUTORY
Influenza
(SECONDARY)
(duration)
... yrs.
3
.mos ..
ds.
9 BIRTHPLACE (city or town)
Hudson
(State or country) mars
10 NAME OF FATHER
Grandes Braces
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
Canada
.
12 MAIDEN NAME OF MOTHER Matilda Yours
13 BIRTHPLACE OF MOTHER (city or town) ..
(State or country)
Sermour
....
14 Iuna Clara Brauch
(Address) No Ctulundard
15
File Septi 251, 1918 Edward & Robbins REGISTRAR
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)
Fred Sarney
LI.D.
aring 1.2319 CF (Address) 01 Chilinfred Mans
* 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 Wertlawn Gente)
DATE OF BURIAL Sefer 25 19/8
20 UNDERTAKER Young& Blake
ADDRESS
Novell
MARGIN RESERVED FOR BINDING
3 SEX
male
7 AGE
PARENTS
Informant
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
particular kind of work, ...
4 COLOR OR RACE
what's
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
mariao
5a If married, widowed, or, divorced
HUSBAND of
(01) WIFE of
Clara Bracele
6 DATE OF BIRTH (month, day, and year)
Years
38
Months
6
Days
119
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED a Trade, profession, or Jeather finisher
(b) General nature of industry, business, or establishment in wbicb employed (or employer) (c) Name of employer
1.00
-
State massachusetts
Registered No. 64 1
City.
No ..
(If non-resident give city or town and State)
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
? statement of occupa-
tion is very important, wie 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 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 linc is provided for the latter statement; it should be used only when necded. 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 spc- 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 fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronehopneumonia ("Pneumonia," unquali- fied, is indefinitc); 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; Chronie interstitial nephritis, etc. The contributory (secondary or inter- current) affection nced not be stated unless important. Example: Measles (disease causing death), 29 ds .; 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 discase 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 earbolic 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 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 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.
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 W. Bulkawiki
(Address) no chelmsford
15
File Sept. 29, 1918 Edward Flo Rolhas
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
m
4 COLOR OR RACE
2.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(01) WIFE of
6 DATE OF BIRTH (month, day, and year)
Jan 1918.
7 AGE
Years
Months
9
Days
If LESS than
1 day, ........ hrs.
or ........ min.
.
8 OCCUPATION OF DECEASED
(a) Trade, profession, nr particular kind of work ..
(b) General nature of industry, business, or establishment in which employed (or employer). (c) Name of employer
CONTRIBUTORY
Probably influenza
(SECONDARY)
(duration)
.yrs ..
mos .. ds.
9 BIRTHPLACE (city or town)
Arwell
(State or country)
10 NAME OF FATHER Wealso yalas Beelbows
11 BIRTHPLACE OF FATHER (city or town) Wiling
(State or country) Russia.
12 MAIDEN NAME OF MOTHER Sophia macken
13 BIRTHPLACE OF MOTHER (eity or town). (State or country) Buccia
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)
(24, 19/8 (Address) Jowile
Stato 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
Je Patrick:
DATE OF BURIAL Les 29 19/18
20 UNDERTAKER
& albert.
ADDRESS 171 aiken
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
123
(City or town)
State
man
Registered No. 65
.. 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
Joseph Bielkowski
St.,
.Ward.
(If non-resident give eity or town and State)
(a) Residence.V
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
16 DATE OF DEATH (month, day, and year)
Sept. 28 1918
17 I HEREBY CERTIFY, TI1.1 Leased fm
19. ......... , to .. ,19.
that I last saw h .....
... alive on
,19
and that death occurred, on the date stated above, at
2 G.
m.
The CAUSE OF DEATH* was as follows :
..... (duration)
1
.. yrs ..
mos ..
ds.
-
PARENTS
MARGIN RESERVED FOR BINDING
1 PLACE OF DEATH
County Jederel
Township no. Chelinefort
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
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 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 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 duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, qr 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. 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 fever (never report "Typhoid pneumonia"); "Lobar pneumonia; Bronehopneumonia ("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; Chronie interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (discase causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (mercly 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 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 earbolie 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.)
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 diseasc, 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.
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.
14
Informant
(Address)
15
Filed. Oct, 2, 1918 Coward- Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)/// 19
17 I HEREBY CERTIFY, That I attended deceased from Sept 22, 1918, to Jehet 29, 1018.
that I last saw hMA alive on
Sept 29, 19 18
and that death occurred, on the date stated above, at ( ?.
.m. The CAUSE OF DEATH* was as follows :
{{duration) .-. yrs ..
mos .....
8
ds.
CONTRIBUTORY
(SECONDARY)
Influenza.
_(duration)
... mos.
yrs ...... .ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death ?
Date of ...
Was there an autopsy ?
no.
What test confirmed diagnosis ?
Samuel
10 (Signed) ..
.] M.D.
/2. 1918 (Address)
* State the DISEASE CAUSING DEATH, or in deaths from VIOLEN 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
€
20 UNDERTAKERZ
ADDRESS
1 PLACE OF DEATH"
County
State
Registered No. 66
Township 7
.or Village ....
.... or
St.,.
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(If ir the Army or Navy of the United States, give rank, organization, etc.,
X
)
(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
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years 2.7
Months
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
(h) 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
>
PARENTS
11 BIRTHPLACE OF FATHER (city or town) ...
(State or country) (
X
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (eity or town). (State or country)
124
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
City
No ....
St., .............. Ward.
(If non-resident give eity or town and State)
una
19
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
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 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, Architeet, 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 cxamples: (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 precisc 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 spc- 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.
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.