USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 47
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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, ctc.
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 onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R 16. 1-'17. 10,000.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
14
Informant
Him. Gumb.
(Address) Or She Tema ford
15
File Oct. 31, 1918 Edward, Rollup
REGISTRAR
MEDICAL. CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Oct. 30. 1918.
17
I HEREBY CERTIFY, That I attended deceased from
Shl. 9
, 19/× Od. 30
1910
that I last saw h alive on
Del. 28
1918
and that death occurred, on the date stated above, at 2,30a.
.... m. The CAUSE OF DEATH* was as follows :
Samowar lancer
1
Oferalan March 1918
.. (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 ?.
(Signed)
41.34. 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
Edson Cemetery
DATE OF BURIAL
Nov., 3. 1918.
20 UNDERTAKER
George W. Healey
ADDRESS
79 BanchSt.
....
(If non-resident give city or town and State)
(Usual place of abode)
Length of residence in city or town where death occurred
15
years
months
days.
How long in U. S., if of foreign hirth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divorced
HUSBAND of
(01) WIFE of
William Gumb
6 DATE OF BIRTH (month, day, and year) Jan. 28.1856
7 AGE
62
Years
Months
9
Days
2
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
at Home
particular kind of work.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
at Home
(c) Name of employer
9 BIRTHPLACE (city or town).
(State or country)
England
10 NAME OF FATHER
William Harriman
PARENTS
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
England.
12 MAIDEN NAME OF MOTHER Sarah Lyone
13 BIRTHPLACE OF MOTHER (city, or town) ..
(State or country)
England
1Kg
N. Chelmsford. (Chty or towuf
1 PLACE OF DEATH
.
County ................................
Middlesex
State
Masa.
Registered No. 91
Township
..... or
City
.No.
or Village Nest Chelmefor School St. nem Cross Roads
.St., ...........
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Sarah ann
Gumb
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
St.,
.. Ward.
MARGIN RESERVED FOR BINDING
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
M.D.
-,
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, 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 duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid 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 disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection necd not be stated unless important. Example: Measles (discase causing death), 29 &s .; 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," etc.),
"Senile," "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 dc- termine definitely. Exanırles: 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, 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 BY
PHYSICIAN.
R 15. 2-'18. 100,000.
MARGIN RESERVED FOR BINDING
1 PLACE OF DEATH Middlesex County .. Township City No 1 2 FULL NAME (a) Residence. No Middlesex (Usual place of abode) Length of residence in city or towo where death occurred years months 3 SEX female 4 COLOR OR RACE white 5a If married, widowed, or divorced HUSBAND of (01) WIFE of 7 AGE Years Months Days - 8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kiod of work. (b) General nature of industry, business, or establishment in which employed (or employer). (c) Name of employer (State or country) massachusetts PARENTS 14 Informant (Address) carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, of certificate. 15 Filed For. 9, 1918 Edum theRolling 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 (State or country) Massachusetts
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Yhor 4
19 45
17
I HEREBY CERTIFY, That I attended deceased from
nor 4
1918
, 19.
to ...
.......
19 that I last saw h ..... alive on ... , ........
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Shelton
....
.(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 ?.
(Signed)
Fund EJamey
M.D.
12 MAIDEN NAME OF MOTHER Ma Sarah Davidson Por7, 19/F (Address) North Chilunfond Seks
* 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 210 Min 2018
20 UNDERTAKER J. S Molton
ADDRESS 220 Chebeford
92
or Village North chelmsford .or
....... ... Ward St.,
(If death occurred in a hospital or institution, give its NAME instead of street and number) mccomb
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.,
.Ward.
(If non-resident give city or town and Statc)
days.
How long in U. S., if of foreign birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
6 DATE OF BIRTH (month, day, and year) nov 4th , 918
If LESS than 1 day, ........ hrs. ......... min.
9 BIRTHPLACE (city or town) ...
north che husband
10 NAME OF FATHER Arthur Frederick me Compt
11 BIRTHPLACE OF FATHER (city or town) ..
Westford
13 BIRTHPLACE OF MOTHER (city or town) It Raymond (State or country) Quebec Canada
-
150
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
State
Maras
excelente Registered No
(City or town)
-
....
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 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 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," "Forcman," "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 Housekcepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation. whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, ctc., 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 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- terminc 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. 10-'18. 5,000.
MARGIN RESERVED FOR BINDING
3 SEX Male 7 AGE Years 91 (State or country) PARENTS Informant so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back of certificate. 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 (h) General nature of industry, business, or establishment in which employed (or employer) ... (c) Name of employer
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
Registered No. 93
Township
Chelmsford
... or Village ..
.... or
St.,
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Wilbur Hick Chamberlin
(a) Residence. No. Chelmsford- Boston Rd.
(Usual place of abode)
Length of residence in city or town where death occurred
years
St.,
Ward.
....
(If non-resident give city or town and State)
days
PERSONAL AND STATISTICAL. PARTICULARS
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)
april 8 1827
Days
0
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
Harmer
9 BIRTHPLACE (city or town).
albany Vt,
10 NAME OF FATHER
Eli Chamberlin
11 BIRTHPLACE OF FATHER (city or town)
albany
(State or country)
1x
12 MAIDEN NAME OF MOTHER acheak Delano 11-1.
13 BIRTHPLACE OF MOTHER (city or town) ..
albany
(State or country)
14 Moro Melin Casa Daughter (Address) Chelmsford
File a 200.9 .2018 Edward J. Battery
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) nov. 8, 1918.
17
I HEREBY CERTIFY, That I attended deceased from
nor.7
19.10. to /202.7, 1918.
1
that I last saw h, .44- alive on
....
har 7, 1918
/
and that death occurred, on the date stated above, at ....
...............
.......... m.
The CAUSE OF DEATH* was as follows :
C
0
(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?
To - Date of
Was there an autopsy ?.
no.
What test confirmed diagnosis ?...
(Signed).
, 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 spacc.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
allamy Ut, Century
DATE OF BURIAL
Chamberlin Hill Nov 10 1918
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
15%
Chelmsford
1 PLACE OF DEATH
County ...
Middlesex
State
mass
City
No.
months
days.
How long in U. S., if of foreign hirth ?
years
months
.. , LI.D.,
Months
7
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
.icoment of occupation. - Precisc statement of oecupa- 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 oeeupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architcet, Locomotive engineer, Civil engineer, Stationary fireman, 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 specification, 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- cifically the oceupations of persons engaged in domestic serviee for wages, as Servant, Cook, Housemaid, ete. It 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 oeeupation whatever, write Nonc. .
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affeetion with respect to timc and eausation), using always the same accepted term for the saine 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, ete., Carcinoma, Sarcoma, ete., of.
(name origin; "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie valvular heart disease; Chronic interstitial nephritis, ete. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 Gs .; Broneho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as " Asthenia," " Anemia" (mcrcly symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con- genital," "Senile,"
ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease ean be ascertained as the cause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State eause 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 - nomicide; 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 eause of death approved by Committee on Nomenelature 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 eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due 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.
MARGIN RESERVED FOR BINDING
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should bo so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
14
Informant ..... (Address) Middlecy St. both Cheles ford
15
Filed Nov. 22.2018 Edward Sporting
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Ihr 19
19 / /
17 I HEREBY CERTIFY, That I attended deceased from Nov ing, 1918, to Nov. 19, 1918 , 197
that I last saw h WW alive on
200.19, 1918
and that death occurred, on the date stated above, at ...
7.30Pm
The CAUSE OF DEATH* was as follows :
Bundopneumonia
........
CONTRIBUTORY
Difluenza
2
(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 ?
holand
(Signed)
James ft
MI.D.
* 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 space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVALYance St. Galiny. Queter mero
DATE OF BURIAL m 2× 10/8
20 UNDERTAKER
ADDRESS my 324 mayget fra
152
Chelica ford
STANDARD CERTIFICATE OF DEATH
(City/or tow.
1 PLACE OF DEATH
County ..
Middlesex
Mary
Registered No. 14
Township
Chelios ford
State Into Chelewis ford ..... or
.. or Village ....
Meddla Ut.
... St., ..
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(a) Residence.
No ..... /
Middlecy It. both Cheluiofond St.
.Ward.
(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
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