USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 45
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
R 15, 1-'18. 100,000.
1
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
1 PLACE OF DEATH
County ................
middlesex
State.
mars
Registered No. 84
City or Town
howell
No. howell Yen
to Rio St ......
Ward
(If death occurred in a hospital or institution give its NAME instead of street and number)
2 FULL NAME.
Eleanor W. Bonne
(a) Residence. State.
mass
City or Town helmare
... No.
St.
(Usual place of abode)
Length of residence io city or town where death occorred
years
mooths
days
How long io U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLORIOR RACE
Female White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Gerald 8
6 DATE OF BIRTH (month, day, and year)
-
Days
If LESS thao
1 day ......... brs.
or ........ [. ..
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
at& t0mg
9 BIRTHPLACE (city or town) Upper Leigh eig
Fa
10 NAME OF FATHER George Weightman
11 BIRTHPLACE OF FATHER (city or town) ..
(State or country)
England
12 MAIDEN NAME OF MOTHER reknown
13 BIRTHPLACE OF MOTHER (city or town) .. (State or country-)
Informant
Husband
(Address)
Chelocal Por
15 Get, 14, 1918. X,
Six Registrar of city of town where death occurred
Filed.
200 9 1918 Oderand
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Och 11 1918.
17
I HEREBY CERTIFY, That !!
attended deceased from
19.
Cochil1
1918.
.,
............
16
19 18 ..
that I last saw her alive on
and that death occurred, on the date stated above, at 138. ... m. The CAUSE OF DEATH* was as follows :
*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.) Epidemia Influenza
Broncho - Tineumonia
1203.
.... (duration).
... yrs ....
..... mp3.
Y Premature Labor
CONTRIBUTORY.
(SECONDARY)
(duration). -yrs. A
... mos. ........
. ds.
18 Where was disease contract
if not at place of death ?
Chelmsford
Did an operation precede death ?.
Date of.
Was there an autopsy ?_
What test confirmed diagnosis ?...
(Sigoed)
10-1 1918 (Address)
Chelmsford
19 PLACE OF BURIAL, CREMATION, OR REMOVAL MesquehoningTa
20 UNDERTAKER
young + Blake
DATE OF BURIAL 604. 13/ 2018
ADDRESS Lowell
3 SEX
7 AGE
particular kiod of work
(b) General oature of industry,
bosiness, or establishment in
wbich employed (or employer)
(e) Name of employer
PARENTS
14
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
(State or country)
Years
29
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
If STILLBORN, coter that fact bere
MARGIN RESERVED FOR BINDING
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
142 howell (City or tound
Registered No .. ...........
(Place of fleath)
(Place of residence)
(If in the Army or Naffy of the United States, give rank, organization, etc.)
Leoborga. M.D.
Months
10
AVISED 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- 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 needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Forcman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," 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 houschold 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 Nonc.
Statement of causa 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 sainc disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of.
(name origin; "Cancer" is less definite; avoid usc of "Tumor" for malignant neoplasms); Mcasles; 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 .; 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," "Scnilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shock," "Urcmia," "Weakness," etc., when a definite disease ean be ascertained as the cause. Always qualify all discases 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 dc- 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 (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." Recommendations on statement of cause of death approved by Committee en Nomenclature of the American Medical Association.)
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, 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.
MARGIN RESERVED FOR BINDING
City 3 SEX Gerale particular kind of work (State or country) PARENTS 14 (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, 15 N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (b) General nature of industry, business, or establishment io which employed (or employer) (c) Name of employer
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
14.3 Weer Chelist and (City or town)
1 PLACE OF DEATH
County.
middlesex
State
massachusetts
.or Village.
.or
(If death oeeurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME.
Oda W. Ghlou
(a) Residence. 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
4 COLOR OR RACE
what
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)
7 AGE 18
Years
Months
Days
/
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
niels
9 BIRTHPLACE (city or town).
Near Chelmsford
muss
10 NAME OF FATHER Care Ohlson
11 BIRTHPLACE OF FATHER (eity or town)
(State or eountry) Sevreden
12 MAIDEN NAME OF MOTHER Lila E- Erickson
13 BIRTHPLACE OF MOTHER(city or town) .. (State or country )
Sucede
Informant
Elvia COhilsen
File Oct. 11, 1918 Edward J. Ro160g REGISTRAR
16 DATE OF DEATH (month, day, and year) Car11 19/8
17
I HEREBY CERTIFY, That I attended deceased from
Oct- 4-
19/8, to
Del. 11
1968
Od. 11
that I last saw her alive on
1968
and that death occurred, on the date stated above, at
2 G.
.m.
The CAUSE OF DEATH* was as follows :
Buncho -forummania
.. (duration)
... yrs ...
mos ..
7
ds.
CONTRIBUTORY
(SECONDARY)
Influenza
.(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 ?...
Fund Ellarney
(Signed)
I.I.D.
Del-1918 (Address)
* State the DISEASE CAUSING DEATHI, 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 spaec.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Wasa Chelmsford
DATE OF BURIAL Od. 12. 1918
20 UNDERTAKER
ADDRESS
Hang & Blake 2 20mill Man
Registered No .. 85
Township
Wass Chelmsford
No ...
St.,
Ward
St.,
Ward.
(If non-resident give eity or town and State)
MEDICAL CERTIFICATE OF DEATH
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census aod 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, 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 "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- 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 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 "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 use of "Tumor" for malignant ncoplasms); Measles; Whooping cough; Chronie valvular heart disease; Chronie interstitial nephritis, etc. The contributory (secondary or inter- current) affection necd not be stated unless important. Example: Measles (disease eausing 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 cause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ctc. 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 sueh, 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 fraeture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Rceommendations 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, cte.
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 circumstanees unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
motor
R 15. 1-'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 STANDARD CERTIFICATE OF DEATH
14,4
1 PLACE OF DEATH
County.
State
or Village North Chelmsford. .. or
St .. ... Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Peter Francis
Lavill
2 FULL NAME
(If ir the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No
Miofuld Si
St.,
.Ward.
(Usual placc of abode)
Length of residence in city or town where death occurred
0 years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male white
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE Years
.
32
Months
Days
If LESS than 1 day, ........ hrs. or ......... min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
auto Repairer
(b) General nature of industry, business, or establishment in which employed (or employer) . (c) Name of employer
9 BIRTHPLACE (city or town).
Lowru
(State or country)
10 NAME OF FATHER James Lavill
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country) Balance
12 MAIDEN NAME OF MOTHER Delia Yelboy
13 BIRTHPLACE OF MOTHER (city or town) .... (State or country) trivand V.
14
Informant
Detic
Yavril
(Address)
15
Filed Oct. 15 . 1918 Edand Rattus
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Oct 14 1918
17
I HEREBY CERTIFY, That I attended deceased from
Det 1, 1918, to.
Qat
14, 19 18
that I last saw h.UMA .. alive on
Bet
4, 1918
and that death occurred, on the date stated above, at
4.300 um. The CAUSE OF DEATH* was as follows :
(duration) .yrs ..
mos ..
ds.
CONTRIBUTORY.
(SECONDARY)
fluenza
.(duration)
yrs ..
.mos ..
6
ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death? NO Date of.
Was there an autopsy ?.
What test confirmed diagnosis ?
(Signed)
ames
M.D.
101, 19 16(Address)
** State the DISEASE CAUSING DEATII, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional spaee.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Di Patricks Yourer
DATE OF BURIAL Oct. 15 1918
20 UNDERTAKER ADDRESS John Ragas 445 Forhaus Sl.
source mais
(City or town) Iwas Registered No. 86
Township
City No ...
.......
.....
(If non-resident give city or town and State)
MARGIN RESERVED FOR BINDING
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 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, 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 necded. As examples: (a) Spinncr, (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, Houscmaid, ctc. 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 Nonc.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, 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 (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," '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 carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on 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 strcet, or onc 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.
MARGIN RESERVED FOR BINDING
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
STANDARD CERTIFICATE OF DEATH
(City or towns Registered No. 87
Township
State Village Inthe Shell And or
... or
St.,
.. Ward
(If death oceurred in a hospital or institution, give its NAME instead of street and number)
Catherine Br.
Waneer
2 FULL NAME
WI in the Army or Navy of the United States, give rank, org (mization, etc.)
(a) Residence. No. mt
avant
St.,
Ward.
(Usual place of abode"
Length of resideoce io city or towo where death occurred
years
mooths
days.
How long io U. S., if of foreign birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Verals Mita
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) In 2 5. 1905
7 AGE
Years
/2
Months
10
Days
2/
If LESS than 1 day ......... hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, professioo, or
School Sind
particular kiod of work
(b) General nature of industry,
business, or establishmeot in
"1
,١
which employed (or employer) ....
(c) Name of employer
9 BIRTHPLACE (city or town)
Chelwe ford
(State or country)
Maso
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
Ireland
12 MAIDEN NAME OF MOTHER Otherry Min Cala
13 BIRTHPLACE OF MOTHER (city or town) ...
(State or country)
Dielands
14 Paties Vary Gather
Informant
(Address)
booth Chelmsford maas
15 Oct. 21, 1918 Edward S Rating REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Ost 16 1918
17
HEREBY CERTIFY, That I attended deceased from
Oct 12
1918,
to.
Qat 16, 2018
that I last saw hea alive on
0
15,1990
...
and that death occurred, on the date stated above, at
ya
( ... m.
The CAUSE OF DEATH* was as follows :
Influenza
(duration)
.yr's ...
mos .....
6
CONTRIBUTORY
(SECONDARY)
.(duration)
yrs ...
... mos ....
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death? w
.Date of.
Was there an autopsy ?.
What test confirmed diagnosis ?
10 (Sigoed)
/18,19
(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
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