USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 43
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months
days.
How long io U. S., if of foreigo birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced,
HUSBAND of
(or) WIFE of
Patrichoz
6 DATE OF BIRTH (month, day, and year)
-
Months
Days
If LESS thao I day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
9 BIRTHPLACE (city or town).
(State or country)
1 Gulmiford
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (city of- town).,
(State or country)
12 MAIDEN NAME OF MOTHER un Eceuz
13 BIRTHPLACE OF MOTHER (city or town) (State or country))
15 Oct. 8 0 18 Emand & Robbin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
17 I HEREBY CERTIFY, That I attended deceased from Oct 3. 1916, ., to. ........
that I last saw h ...... alive on
1918
H.P. and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows :
Cerebral Hemm
......
- (duration)
yrsmos ...
.. ds.
CONTRIBUTORY.
(SECONDARY)
.(duration) .
.. yrs ...
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 ?
0 .(Sigoed)
alan
M.D.
8. 19/8 (Address)
* 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
19
ADDRESS
MARGIN RESERVED FOR BINDING
City ..... 2 FULL NAME.“ 3 SEX Female 7 AGE Years 13 (a) Trade, profession, or particular kind of work .. PARENTS 14 Informant (Address) of certificate. 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, File N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (h) General oature of industry, business, or establishment in which employed (or employer) .... (c) Name of employer
(If ir, the Army or Navy of the United States, give rank, organization, etc.)
St., ................ .. Ward.
(If non-resident give city or town and State)
19/
4
.. mos ....
ds.
21
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, c. g., Farmer or Planter, Physician, Compos- ilor, 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 linc 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 laborcr, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekcepcrs 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 domestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on aceount 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 "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of _.
(name origin; "Cancer" is less definite; avoid usc of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronie interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; 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," etc.); "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shoek," "Uremia," "Wcakness," etc., when a definite disease can be ascertaincd 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 carbolic acid - probably suicidc. 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, ctc.
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
PHYSICIAN.
BY
R 15. 2-'18. 100,000.
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.
The Commonwealth of Massachusetts
Cheles in
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
State
.or Village. Ants Chelles ford ...... 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.)
St.,
Ward.
(If non-resident give city or town and State)
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Mals Mater
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) Married
5a If married, widowed, or divorced
HUSBAND of
(01) WIFE of
Elisabeth Mc Sid
G DATE OF BIRTH (month, day, and scar)
1589
If LESS thao I day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
operation
particular kiod of work.
(b) General nature of industry,
husiness, or establishment in
which employed (or employer)
(c) Name of employer
Cala mill
PARENTS
14
Informant
Mes Elizabeth Seven til
(Address)
with Cheles ford Mak
15 Filed Oct. 10, 1918 Edward Robbins REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) October 8, 1918
17
I HEREBY CERTIFY, That I attended deceased from
Sept. 29.
, 1918, to 021=8
.......
19.18-
that I last saw h UM alive on
out.7
, 19 18
and that death occurred, on the date stated above, at 12:45 pm. The CAUSE OF DEATH* was as follows : acute pneumonia ivalori
right middle tower, and
left bir lobes.
(duration)
... yrs ...
.mos ...
ds.
CONTRIBUTORY
Influenza
(SECONDARY)
(duration)
.. yrs.
.mos ..
18 Where was disease contracted
if not at place of death?
Lowell?
Did an operation precede death?
to Date of -
Was there an autopsy ?.
no
What test confirmed diagnosis ?.
all classical Aigus
(Sigoed)
Fredauch. Lombert
M.D.
10/101918 (Address) Tingslough, mass
* 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. Patur Cemetery
DATE OF BURIAL Oct 10 1018
20 UNDERTAKER
ADDRESS
Cours +. Amwell Im 324/ Haufatt
MARGIN RESERVED FOR BINDING
9 BIRTHPLACE (city or town)
Sort Land
(State or country)
10 NAME OF FATHER John Devlin
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
Sent Land
12 MAIDEN NAME OF MOTHER Margaret Drawing
13 BIRTHPLACE OF MOTHER (city or town) .... (State or country)
Ver land
1/36
(City or toan) Registered No. 78
Township
City. No ..
James Devlin
......... ....
(a) Residence. No. (Usual place of abode) Length of residence in city or towo where death occurred years
mooths
days.
How loog in U. S., if of foreign birth ?
years
4 COLOR OR RACE
7 AGE
Years
3/
Months
-
Days
8
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATHI [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 agc. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, ctc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) 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 .- 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: Cercbrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of.
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; 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 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col-
lapse," "Comna," "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 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 due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 2-'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,
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
howell3>
(City or towny
1 PLACE OF DEATH,
County middlesex
State
mass
Registered No. 142
79 .. or
City howell
Q or Village.
No ......
Lowell Gen Hospital St. ?
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Still Born ( Bonney
(a) Residence.
No.
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
St.,
Ychelmsford mars
(If non-resident give eity or town and State)
mooths days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female White Single
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 det. 9. 1918.
7 AGE Years
Months
Days
If LESS than 1 day, ........ hrs. or ........ mio.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work ..
(b) General nature of industry, business, or establishment in which employed (or employer) ... (c) Name of employer
9 BIRTHPLACE (eity or town).
Lowell
(State or country) mars
10 NAME OF FATHER Gerald &
PARENTS
11 BIRTHPLACE OF FATHER (eity or town).
(State or country) Pennsylvania
12 MAIDEN NAME OF MOTHER Cleaner W. Weights
13 BIRTHPLACE OF MOTHER (city or town) Upperdeigh (State or country) Pa gr
14 Fathera
Informant
(Address) Chelmsford mass
15 File Det. 14, 1916.1 Sited nor- 9,195 g diman SichCom
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
October 9 2018.
17 I HEREBY CERTIFY, That I attended deceased from
., 19 ...
.......
.. , to.
19
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 :
Still Born
.. (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 ? arthur Gocoloria
(Signed)
M.D.
101, 1918 (Address)
chelmsford mass
* State the DISEASE CAUSING DEATH, orUn deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional spaee.)
DATE OF BURIAL
19 **
ADDRESS Lowell.
MARGIN RESERVED FOR BINDING
of certificate.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL nesqualo
20 UNDERTAKER young + Blake
-...
days. How long in U. S., if of foreign birth ? years
Township
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, Arehiteet, 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 "Laborcr," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborcr, 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, Houscwork, or At home, and children, not gainfully employed, as At sehool 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 use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronehopneumonia ("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 ncoplasms); Measles; Whooping cough; Chronic 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 symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma,' "Convulsions," "Debility" ("Con-
genital," "Scnile," 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 carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., scpsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Casas for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, 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. 10,000.
138
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
WORCESTERI
(City or town)
1 PLACE OF DEATH
County ..
WORDLETER.
State ..
Township
or Village.
.or
Worcester State Hospital
St ..
......
... Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME ........
Harry O Strandberg
(a) Residence.
No.
(Usual place of aboyofden Cove Rd.
Length of residence io city or town where death occorred
years
mooths
days.
How loog io U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(01) WIFE of
6 DATE OF BIRTH (month, day, and year)
1896
7 AGE
Ycars
Months
Days
If LESS than
1 day ......... hrs.
or ........ mio.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Musician
(b) General nature of industry, business, or establishment io which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
Lowell
(State or country) Mass
10 NAME OF FATHER Carl A
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Sweden
12 MAIDEN NAME OF MOTHER Marion Olson
13 BIRTHPLACE OF MOTHER (city or town) ... (State or country) Sweden
14
Informant Records of State Hospital (Address) Worcester
15 Filed Oct 15 19 18
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and ycar)
Oct 9
1918
17
I HEREBY CERTIFY, That I attended deceased from
Sent 5
1918 .
... , to
Oct 9
1918
that I last saw h .. Im ... alive on
Oct 9
191.8 ...
and that death occurred, on the date stated above, at 5 ..... 4.5 ...... A ... m.
The CAUSE OF DEATH* was as follows :
Influenza
(duration)
mos .... 1.1 ... ds.
.... yrs ....
CONTRIBUTORY.
BronchoPneumonia
(SECONDARY)
... (duration)
.yrs.
... mos ..... ....
....... ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death? no
„.Date of.
Was there an autopsy ?.
no.
What test confirmed diagnosis ?
(Sigoed)
Arthur H Mountford
M.D.
10/9 . 197 8( Address)
Worcester
* 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. (Sce reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
West Lawn Cem Lowell Mass
20 UNDERTAKER
GEO SESSIONS SONS CO
DATE OF BURIAL Oct 13 19
ADDRESS
WORCESTER
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.
Registered No 80
City
WORCESTER
.No.
.... ,
St.,
.Ward.
Chelmsford Mass
(If non-resident give city or town and Statc)
22
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of orcupa- 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, 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; (o) 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 - Cool 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.
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