USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 4
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
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- posurc, 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 circumstances unknown, as A person found dcad, etc.
R 18. 33'16. 10,000,
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 Oommmmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
) PLACE OF DEATH
Chelmsford
(No
Town Farm
St. :
Ward)
23.5 Glihans ford (City orfown.) Fif death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
13
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
SEX
male
4 COLOR OR RACE
white
| 5 SINGLE,
MARRIED,
widowed
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Feb.
13
(Month)
(Day)
191 /
(Year)
$ DATE OF BIRTH
nov
7 1832
--
(Month)
(Day)
(Year)
7 AGE
84
yra. 3
mo
6
.ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Fumate
(b) General nature of industry. business, or establishment in which employed (or employer) ...
Sentit.
(Duration)
... yra.
... mos. ds.
Contributory .. (SECONDARY) .......
Duration) ..
.............. y ... ................ mos,
......
... ds.
(Signed)
Tab.14, 1911 (Address)
Chiloptional
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
In the
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death
yrs.
mos.
ds.
State ............ yra.
............ mos.
. ............
Where was disease contracted, if not at place of death 7.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Horefuturs Ceny RecTout
DATE OF BURIAL
10-15 1917
(Address)
Chelmsford
15 bib. 13 7 Edward . Bobbin,
REGISTRAR
17 I HEREBY CERTIFY that attended deceased from
.... , to
Jan 19, 1917.
.
that I last saw him alive on
Jan, 19
197
and that death occurred, on the date stated above, at .....................
The CAUSE OF DEATH* was as follows :
-
9 BIRTHPLACE
(State or country)
Lowell
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
England
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE
OF MOTHER
(State or country)
/
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
James Song
Filed ..
20 UNDERTAKER
MilanPerham
ADDRESS
Chelmsford
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
....
Samuel atherton
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of busband.]
@RESIDENCE
Chelmsford
......
.........
M.D.
10 NAME OF
FATHER
S. arturton
If LESS than
I day ......... hrs.
....
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive 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 nceded. 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 "Laborcr," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm taborcr, Laborer - Coal mine, ctc. Women at home, who arc engaged in the duties of the household only (not paid House- keepers 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. Carc should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- FASE CAUSING DEATHI (the primary affection with respect to time and causation), using always the same accepted term for the same discasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, is indefinite); Tuber-
culosis of laings, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. ....... (name origin: "Cancer" is Icss definite; avoid usc of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ctc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (therely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure,". "Haemorrbage," "Inanition," "Marasmus," "Old age,". "Shock," "Uraemia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL scpticaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ctc.
3. Sudden deathis of persons not disabled by recognized disease, as A death upon the strcct, or onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH E. Chelmsford Bax 102 Center St. ;.. Ward)
E. Chelmsford (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Mrs. Margaret Grantz
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Box 102 Center St. E. Chelmsford
Margaret Lavelle (Herman Grantz)
.......
Registered No.
14
PERSONAL AND STATISTICAL PARTICULARS
1 5 SINGLE,
MARRIED,
WIDOWED, married
1 (Year)
If LESS than
I day ......... hrs.
or ........ min. ?
1
Tet 12, 1917
and that death occurred, on the date stated above, at 10,1m.
The CAUSE OF DEATH* was as follows :
(Duration)
2 mo
.mos.
ds.
.yrs.
Aschina
................
...... .........
Contributory ...............
(SECONDARY)
2.
(Duration).
mos.
ds.
yra.
(Signed)
M.D.
6721.6.1997
X ......... ,
(Address)
..... JOHNSA ......
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
. yrs.
.... mos ..
....
........
In the
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 St. Patrick's
DATE OF BURIAL
Feb. 15. 1917
Lowell, Mass.
20 UNDERTAKER O' Connell & Mack.
ADDRESS
16 Filed Feb. 15 ....
1917 Edward DoNothing .............. REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
...
......
..............
(Month)
(Day)
(Year)
....
I HEREBY CERTIFY that Lattended deceased from
1917, to
.... ,
0
Per, 13.1912
.......
that I last saw h$ 1/ alive on
13
191 / .
....
2 FULL NAME 3 SEX 4 COLOR OR RACE female white OR DIVORCED (Write the word) · DATE OF BIRTH (Month) (Day) 7 AGE 41 & OCCUPATION (a) Trade, profession, or House-wife particular kind of work (b) General nature of industry, business, or establishment In which employed (or employer) .. 9 BIRTHPLACE (State or country) Lowell, Mass. 10 NAME OF FATHER Peter: Lavell 11 BIRTHPLACE OF FATHER (State or country) Ireland 12 MAIDEN NAME OF MOTHER Mary Cuff PARENTS 18 BIRTHPLACE OF MOTHER (State or country) Ireland (Informant) Herman Grantz 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 .... ... yra. mos. ds.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)Box 102 Center St. E. C.
658 Gorham ₺
........
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precisc statement of oeeu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many 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," ete., without more precise specification, as Day laborcr, Farm laborer, Laborer - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At schod or At home. Care should be taken to report specifically 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 DEATH, state occupation at beginning of illness. If retired from business, that faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie 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, peritoneum, ete., Carcinoma, Sar- coma, ete., 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 intereurrent) affection nced not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatie), "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 eause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
( R. W.) it.
---
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX Mall · DATE OF BIRTH 7 AGE B OCCUPATION (a) Trade, profession, or particular kind of work. (b) General nature of industry, business, or establishment in which employed (or employer) .. PARENTS 13 BIRTHPLACE OF MOTHER (State or country) 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 ............... yrs.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE, OF DEATH
1PLACE OF DEATH nexusfra Senteret. acton It
St. : Ward)
{If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Gerold Heelon
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of hneband.] aRESIDENCE Velmiford Senter Lector de
PERSONAL AND STATISTICAL PARTICULARS
+ COLOR OR PACE
hits
15 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
tingle
1
(Year)
If LESS than
I day ........ hrs.
Or ......... min. ?
9 BIRTHPLACE
(State or country Lehineford Sauter Ces
10 NAME OF FATHER fulham F. HEElon
11 BIRTHPLACE OF FATHER Make or country) ForEll Mass
12 MAIDEN NAME OF MOTHER Sinorg F. Mechan
Jervell Mail.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
William Arelor.
(Address) 12 Ermungs Place Forall
16 Filed. Feb 15 /1917 Edward & Robbery
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
1917
(Year)
(Day)
17 I HEREBY CERTIFY that I attended deceased from
Birth
... ,
191
Pub. 5
....... , to
1917
that I last saw h ...
alive on
....... )
191
and that death occurred, on the date stated above, at .....
................ m.
The CAUSE OF DEATH* was as follows :
Congenital Syphilis
...
.. (Duration)
yrs.
mos.
ds.
.....
.........
..............
(Signed)
Anta J. Ocorona
....
M.D.
tab. 14, 191 (Address).
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
In the
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 . detriches
DATE OF BURIAL
Fal: 15 1912
20 UNDERTAKER
ADDRESS
Sowell
..
15
Registered No.
14
.....
(Month)
(Day)
9
mos.
ds.
....
23° Chelmsford (City or /own.)
Contributory
(SECONDARY)
-
(Duration).
.... yrs.
......... mos.
ds.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers 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 domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ........ ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease eausing 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 ehildbirth or miscarriage, as "PUER- PERAL septicaemia,". "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suieidc, Homicide, ctc.
2. Deaths supposedly eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15-8-'15. 100,000.
-
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 Commonwealin of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
CHELMSFORD
..............
(No. 1542 Gorham St
St. :
Ward)
238
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Telen C. Whiting Sears
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
43 Marlborough St.
Registered No.
16
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
Female
' COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
single
$ DATE OF BIRTH
Aus
(Month)
(Day)
(Year)
7 AGE
19
...... yrs ..
6
mos.
ds.
Or ......... min. ?
S OCCUPATION
(a) Trade, profession, or
particular kind of work
Student
(b) General nature of Industry,
business, or establishment in
which employed (or employer).
Student
9 BIRTHPLACE
(State or country)
Holyoke Mass
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Brattleboro Vt.
12 MAIDEN NAME
OF MOTHER
Catherine Coonerty
1$ BIRTHPLACE
OF MOTHER
(State or country)
Albany Vt.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Mrs. Catherine Sears
(Address)
43 Marlborough St.
Filed treb 16, 1917. Edward FROMmy
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
Jan 27, 1917 to 34 15
1917.
that I last saw hace alive on.
1917,
FLX 15
. .
......
and that death occurred, on the date stated above, at 3 m.
The CAUSE OF DEATH* was as follows :
Julnucleo & Junge
.. (Duration)
...... yrs.
................ mos. .
.ds.
Contributory
(SECONDARY)
........
...... (Duration)
................. yrs.
................ mos.
(Signed)
gnatthem B. Mahoney
M.D.
Jur 16
1917 (Address) 169 Minwmaoist
.....
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS). .
At place
of death
... yrs.
.. mos.
ds.
State ............ yrs.
............ mos ..
In the
Where was disease contracted, If not at place of death ?. Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL brattleboro Vt.
DATE OF BURIAL
Feb.18
7
191
20 UNDERTAKER John L. McDonough
ADDRESS
176 Gorham
15-
(Month)
(Day)
191.7
(Year)
18971
MARGIN RESERVED FOR BINDING
10 NAME OF
FATHER
1. Frank Sears
If LESS than
I day ......... hrs.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. g .. . Farmer or Planter, Physician, Compositor, Architect, Loco- motive 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 lineis 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- keepers 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 domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of ... ................... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage,", "Inanition,". "Marasmus," "Old age," "Shock," "Uraemia," "Wcakness," etc., when a definite disease can be ascertained as the eause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia,". "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
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.