USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 41
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2 FULL NAME
Clara Brault
(a) Residence.
State Mass,
City or Towho Chelmsford No.
(Usual place of abode)
Length of residence io 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
Female White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
widowed
5a If married, widowed, or divorted
HUSBAND of
(or) WIFE of
Ernesta.
6 DATE OF BIRTH (month, day, and year)
-
If LESS than
I day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, professioo, or
particular kind of work ..
at Home
9 BIRTHPLACE (city or town).
England
(State or country)
10 NAME OF FATHER Jandar Williama
11 BIRTHPLACE OF FATHER (city or town) ..
(State or country)
England
12 MAIDEN NAME OF MOTHER Vintention
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
England
14 Um. H.Williams
Det. 7. 1918 Filed 1200.9.1918 @ Registrar of city of town where death occurred ed Y. Robbing
Registrar of city or towo where deceased resided
16 DATE OF DEATH (month, day, and year)( October 3 19 18.
17
I HEREBY CERTIFY, That I attended deceased from
Sent. 28, 1
19
18 to 605. 3
... 19 18
that I last saw her
.... alive on ..
-
11.32. .m. The CAUSE OF DEATH* was as follows :
3
1911.
and that death occurred, on the date stated above,
* 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.) Lobar Freun
Primary)
... (duration) ..
yrs ..
Mos. 6 ds.
CONTRIBUTORY
(SECONDARY)
Influenza
mos ...
co
ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death?
-
Date of
Was there an autopsy ?.
What test confirmed diagnosis?
(Signed)
+300 E. Kagney
, M.D.
0-4,19 18 (Address)
no. Chelmsford mars
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Weitlawn Cem,
DATE OF BURIAL Jet. 50 1918
ADDRESS
20 UNDERTAKER Young + Blake
Lowell
MARGIN RESERVED FOR BINDING
7 AGE (h) General oature of industry, bosiness, or establishment in which employed (or employer ) .... (€) Name of employer PARENTS Informant (Address) 15 of certificate. N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, If STILLBORN, eoter that fact here
The Commonwealth of Massachusetts
1 PLACE OF DEATH
City or Townhowell
1608 , Florence
6
(If in the Army of Navy of the United States, give rank, organization, etc.)
St.
MEDICAL CERTIFICATE OF DEATH
Years
39
Months
6
Days
.(duration).
yrs.
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - 7 ant, of occu. tion is very important, so that the relative healthfulness 01 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, c. g., Farmer or Planter, Physician, Compos- itor, Architeet, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial cinployments, 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, 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 .- Namc, 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., Careinoma, Sarcoma, etc., of.
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broneho- pneumonia (secondary), 10 ds. Never report mere syinp- toms or terminal conditions, such as "Asthenia," "Anemia" (increly symptomatic), "Atrophy," " "Col- lapse," "Coma," "Convulsions," "Debility" ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "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 carbolie acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. g., sepsis, tetanus) may be stated
under their.
on state: nvor by Committee (Recommendations
on Nomci- .. ' Association.)
Under the provi-
Cases % r
dgths 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 303. 6-'18. 50,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
122
(City or town)
1 PLACE OF DEATH
County meddecred.
Township no. Chelmsford
.or Village.
State.
mas.
Registered No. 71
.or
.
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Claire.
Boucher.
(If in the Ariny or Navy ofthe United States, give rank, organization, etc.s.
(a) Residence.
No.
(Usual place of abode)
Length of residence in city or town where death occurred
years
vy ore delrey.
St., ............ .Ward.
(If non-resident give city or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
21.
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) Det.1-1918.
7 AGE Years
Months
Days
3
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade. profession, or particular kind of work ...
(b) General nature nf industry, business, or establishment in which employed (or employer) ... (c) Name of employer
9 BIRTHPLACE (city or town).
go. Chelmsford
(State or country) maso/
10 NAME OF FATHE Chilias Boucher
11 BIRTHPLACE OF FATHER (city or town) A Yohectare (State or country) vV.
12 MAIDEN NAME OF MOTHER Delia Levasseur
13 BIRTHPLACE OF MOTHER (city or town) Lewiston (State or country) me
14 Chilian Boucher
Informant
(Address)
Her Chilometri
15 File
Qcs. 4 19 18 Edward , Robbins
REGISTRAR
16 DATE OF DEATH (month, day, and year) Od. 3 19
17
I HEREBY CERTIFY, That I attended deceased from
Del-1
19.05, to
Ocf, 3
1920
....
Del. 3
that I last saw halive on
, 1918
and that death occurred, on the date stated above, at 10 6ª.
The CAUSE OF DEATH* was as follows :
... m.
actives
(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 ?...
Lud Varney
(Signed)
Rep.41915 (Address)
Hot Chelengste Odam
M.D.
** State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional spaee.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL 1 Cemetery It Josephchelmsford
DATE OF BURIAL
Oct. 2/1918
20 UNDERTAKER
2. albert
ADDRESS
171 arben
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, N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
City
No ...
months
days.
How long in U. S., if of foreign birth ?
years
MEDICAL CERTIFICATE OF DEATH
MARGIN RESERVED FOR BINDING
PARENTS
3
.......
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precisc statement of occupa- tion 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, 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 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 houschold only (not paid Housekeepers who reccive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- eifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the oceupation 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- eated thus: Farmer (retired, 6 yrs.). For persons who have no oceupation 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 indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of_
(name origin; "Caneer" 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 need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (sccondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" etc.), ("Con- genital," "Senile," "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," ete., when a definite disease can be aseertained as the cause. Always qualify all discases resulting from child- birth or misearriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under 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 disease, as A death upon the street, or one supposed to be duc to Alcoholism, ete.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
so that it may be properly classified. Exact statement of OCCUPATION is vesyrimportant. See instructions on back 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
und
1 PLACE OF DEATH
County ...
Middlesex
.State
Township
or Village.
City No. Gorham
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Quinn
2 FULL NAME. .... diinthe Army of Navy of the United States, give rank, organization, etc .: ) ...
(a) Residence. No. (Usual place of abode) Length of residence in city or town where death occurred years
900 ham It
St.,
Ward.
(If non-resident give city or town and State)
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX malz
4 COLOR ORRACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
manuel
5a If married, widowed, or divorced HUSBAND of (or) WIFE of annie Selmove
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
51
Months
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade. profession, or
particular kind of work.
machaut
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
Cual and Wood
9 BIRTHPLACE (city or town) ..
2
(State or country) Euland1
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city er town) (State or country) Juland
12 MAIDEN NAME OF MOTHER mary murphy
13 BIRTHPLACE OF MOTHER (city gr town) .... (State or country) Ruland
14
Informant .
annie Lei, Wife
(Address)
enham
15
File a Oct. 7 : 918 Edward ). Jobbing
REGISTRAR
16 DATE OF DEATH (month, day, and year Oct U. 1918
17 I HEREBY CERTIFY, That I attended deceased from 02/ 2
..... , to ..
,19/P
that I last saw h han alive on
... 19 18
and that death occurred, on the date stated above, at
2 P
.m.
The CAUSE OF DEATH* was as follows :
Endocardite
(duration)
.. yrs ..
mos.
2
.ds.
CONTRIBUTORY
.(duration)
. yrs ...
mos ...
7
ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death?
_Date of.
Was there an autopsy ?.
What test confirmed diagnosis ?
(Signed)
M.D.
apps, 19 (Address) 25Wanted
* 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 spacc.)
19 PLACE OF BURIAL CREMATION, OR REMOVAL
DATE OF BURIAL Oct/ 1918
ADDRESS
20 UNDERTAKER en Sonwill you Makedist.
1/30
(City ortown)
Registered No. 12
..... or
St., ..
......
.. .
months
MEDICAL CERTIFICATE OF DEATH
1
MARGIN RESERVED FOR BINDING
.
1
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation, - Precise statement of tion is very important, so that the relative healthful. 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, 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- 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, statc 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 discase. 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, 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 (secondary or inter- current) affection necd not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (sccondary), 10 ds. Never report mere symp -. toms or terminal conditions, such as "Asthenia," "Anemia" (inerely 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 aseertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolie acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (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 violenec, 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.
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.
15
Fil Ext. 5, 1915 Edward & Robbins
REGISTRAR
16 DATE OF DEATH (month, day, and year) Det 5 19 / 4".
17 Sept. 28
HEREBY CERTIFY, That I attended deceased from
1918, to
to.
Oct 5.
, 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 :
&
Influenza
.. (duration)
yrs ..
mos.
ds.
CONTRIBUTORY.
(SECONDARY)
... (duration)
.yrs ....
mos ..
7
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?..
.Date of
Was there an autopsy ?.
What test confirmed diagnosis ? ...
(Signed)
10-2, 1918 (Address)
Clubufora, Mais
* 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 Pine Ridgelem. Cef. 8
DATE OF BURIAL 19/8
ADDRESS
20 UNDERTAKER7
Walter Fecham Shedensford
/3/
1 PLACE OF DEATH
County ..
Township
Chilis Fund
or Village ...
Centre
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. actor
( 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
& SEX Fagale
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
74
Months
4
1
Days
8
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Machinist
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
Nowtridge
(State or country) England.
10 NAME OF FATHER Solowhen Elliot
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Елдесна
12 MAIDEN NAME OF MOTHER lacale Gook
13 BIRTHPLACE OF MOTHER (eity or town). (State or country) Сидфанов
14 Informant (Address)
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
Registered No. 73
State.
John Lewis Elliall-
St.,
Ward.
(If non-resident give city or town and State)
MEDICAL CERTIFICATE OF DEATH
MARGIN RESERVED FOR BINDING
M.D.
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Cersus and American Public Health A.
Statement of occupation. occupa-
tion is very important, so that the loan. s of
various pursuits ean be known. The question apples 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, 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," ete., without more precise specifieation, as Day laborer, Farm laborer, Laborer - Coal mine, ete. 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- eifieally the occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, ete. It 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 faet may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
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