USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 5
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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, etc.
2. Deaths supposedly eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15-8-'15. 100,000.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state /
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH Maso. (Beth Salford (No.
St. :
......... Ward)
.
Charlie
17
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
Tab. 16
1917, to take 21
1917
that I last saw h M alive on.
Fab 20
.... .
1917
....
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
.
Gente Solar Pneumonia
(Duration) .
.ds.
mcs.
.. yrs.
Contributory. (SECONDARY)
... (Duration) ...
............. yrs.
mos.
.ds.
(Signed)
Anche . Scoloria,
M.D.
Farba 22 1957 (Address)
Chelmsford, Mass.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
... yrs
.. mos ..
... ds.
State.
.yrs.
In the
.mos.
ds.
Where was disease contracted, if not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
1917
20 UNDERTAKER Sentimos + 12
Frown.
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
1 5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1
(Month)
(Day)
.... , (Year)
If LESS than
[ day ......... hrs.
.mos.
ds.
or ......... min. ?
(a) Trade, profession, or particular kind of work
N
(b) General nature of industry, business, or establishment in which employed (or employer) ...
11 BIRTHPLACE OF FATHER (State or country)
Votardingham W.s
12 MAIDEN NAME OF MOTHER
Hard.
18 BIRTHPLACE OF MOTHER (State or country)
Forstand Mir.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
-
(Address)
16 Filed. Feb. 23, 1917 Edward J. Robbins
REGISTRAR
239
7
(Month)
(Day)
(Year)
21
4 COLOR OR RACE
Athila.
3 SEX · DATE OF BIRTH 7 AGE & OCCUPATION 9 BIRTHPLACE (State or country) 10 NAME OF FATHER PARENTS CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ............. (Informant) important. See instructions on back of certificate.
1
ADDRESS 96-Branche UL.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the oceupations of persons engaged in domestic 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 indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- CASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- roma, 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, ete. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage,", "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., when a definite disease ean be aseertained as the eause. Always qualify all Aiseases resulting from ehildbirth or miscarriage, as "PUER- PERAL septicaemia,". "PUERPERAL peritonitis," etc. State eause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15-8-'15. 100,000.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
' FULL NAME $ SEX ... ' AGE PARENTS important. See Instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very ........
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
(Lehnsford.
.(No
Boston Rd
......
St. ;....................
.Ward)
Burt Emerson
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Chelmsford
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
February
25
1912
..... (Month)
(Day)
(Year)
· DATE OF BIRTH
May
1838
1 (Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from Hab. 3, 1917, to .. Feb. 25
If LESS than
[ day ........
.. hrs.
that I last saw him alive on.
Fab. 24
.. 1917.
and that death occurred, on the date stated above,
t 7 a.m.
The CAUSE OF DEATH* was as follows :
1
Broncho- priemone-
(Duration)
.. yrs.
........
.... mos.
21 ds.
Contributory ...
Endocarditis
...............
(SECONDARY)
Several
(Duration).
... yrs.
.mos.
ds.
(Signed)
Canada toward
M.D.
46. 2.6. 1917 (Address)
Chebradorá
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
.yrs. ....
... mos.
In the
ds.
State ............ yrs. ..
.... mos. ..........
... ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence. ...... .............
19 PLACE OF BURIAL OR REMOVAL
Forfactice Cene.
DATE OF BURIAL
Feb. 27
1917
(Address) Lawrence Maro
15 Filed tab. 27, 1917 Edward , Rolling
REGISTRAR
6
10 NAME OF
FATHER
Brepaul merson
11 BIRTHPLACE
OF FATHER
(State or country)
Chelmsford
12 MAIDEN NAME
OF MOTHER
HannahA. Bradford
18 BIRTHPLACE
OF MOTHER
(State or country)
3) Saleux N.t.
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
fleury Emerson (som)
20 UNDERTAKER
Walter Tenham
ADDRESS
Chelmsford
2110 Chelmsford ........... (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
18
' COLOR OR RACE
Male White
5 SINGLE,
MARRIED
WIDOWED.
OR DIVORCED
(Write the word) arries
78 Min. 9 mos. 25 de
or ......... min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired
(b) General nature of industry. business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Chelmsford
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. g .. Farmer or Planter, Physician, Compositor, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same diseasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- eoma, etc., of ........... .(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (mcrcly symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age,". "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deathis 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 dcad, etc.
1
COUPON NO. 2.
(24)
Registered No ...... 9.13.
No. of Permit ..
3
To be detached as per instructions on the back of this coupon.
Name Arthur Abrahamson
Age 25 vr 10 mo 27 days
Date of Death Feb. 9, 1017
Place of Death ........
Ayer, Mass
Date of Shipment ....... E.e.b ........ 12 ..... 1917
Hour of Train.
.8.20 .A.M.
State of ....... Mass ..
Ullnight Son.
Signature Board of Health Official.
Shipping Embalmer.
Cause of Death Compound fracture of skull Cemetery West Chelmsford
City of Town West Chelmsford
COUPON NO. 2.
This Coupon to be detached ONLY when required for record in cities or towns, otherwise to be filed with the local board of health or town clerk where the interment is to be made, and by the superintendent or person in charge of cemetery.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No St. John's Hospitals.
Ward)
(City or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
14
Registered No.
394
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
march 1
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from February 121911 , to march 7 1
that I last saw het alive on. 1911 and that death occurred, on the date stated above, at LR .m.
The CAUSE OF DEATH* was as follows :
Gall Stones Operation
.. (Duration) ................ yrs.
..... mo3.
ds.
Contributory.
Septic myocarditis
.....
(SLCONDARY)
.... (Duration) !
....... ds.
James, 7
Hobarn
M.D.
(Signed)
Mar211
1911
(Address) No Chelmsford Mais
.....
* If death followed injury or violence tho certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
ds.
At place
of death
yrs.
... mos. .......
ds.
State.
.......... yrs.
... mos.
in the
....
Where was disease contracted,
If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
no. Chelmsford mass Mar. 4 19/ 7
"0 UNDERTAKER Simmonst Brown
ADDRESS
Lowell.
PLACE OF DEATH
Lowelf mass
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
.......
1 SEX
4 COLOR OR RACE
Female White
DATE OF BIRTH
(Month)
(Day)
? AGE
54
B OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of Industry.
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
England
10 NAME OF
FATHER
John Ruda
Huda
.
11 BIRTHPLACE
OF FATHER
gland
(State or country)
12 MAIDEN NAME
OF MOTHER
unknown
PARENTS
13 BIRTHPLACE
England
OF MOTHER
(State or country)
(informant)
auslands
important. See instructions on back of certificate.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
....
............. yrs.
-mos.
-ds.
5 SINGLE
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word) Married
1
1
-
(Year)
-
If LESS than
l day ........ hrs.
or ......... min. ?
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)
no Chelmsford mais
15 mar 57. 191.
Filed _.
REGISTRAR!
Lowell
24/2
amelia la Russos so
amelia, Ruda-
Benjamin
@RESIDENCE
no. Chelmsford mass.
PERSONAL AND STATISTICAL PARTICULARS
-
191.
.......
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to cach 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, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the naturc of the business or industry, and therefore an additional linc is provided for the latter statement; it should be used only when nceded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the sceond statement. Never return "Laborcr," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.
Statement of cause of death. - Namne, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasins); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility". ("Congenital," "Senile," cte.), "Dropsy," "Exhaustion," "Heart failure,". "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," ctc. State cause for which surgical opcration was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc
4. Deaths under circumstances unknown, as A person found dead, etc.
R 18. 3-'16. 10,000.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelunsford
(No.
St. :
Ward)
Peter percival Hollander
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.1
@RESIDENCE
cheliusfrit
Registered No.
20
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
200
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCEBylo
(Write the word)
16 DATE OF DEATH
mar
2
(Month)
(Day)
1917
(Year)
· DATE OF BIRTH
March
(Month)
(Day)
191 (Year)
" AGE
0
.. yrs.
0
mos.
0
ds.
or ........ min. ?
...
If LESS than
I day, ..
.... hrs.
that / last saw h ............. alive on.
191
and that death occurred, on the date stated above, at 1 0
The CAUSE OF DEATH* was, as follows :
Still born
(Duration).
yrs.
mos.
ds.
Contributory .. (SECONDARY)
(Duration)
.... yrs.
mos.
ds
(Signed)
har 3
........ 191 ... ] ..... (Address).
Westland Hinge
....
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
. mos.
ds.
State
... yrs.
In the
......
.... ....
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Tine Wedge Chelmustard.
DATE OF BURIAL
Hav. 3
1917
ADDRESS
16 File Mar. 3 (9) Edward L Telling REGISTRAR
.....
243
(City or town.) [If death occurred in a hospital or institution, give Its NAME instead of street and number.]
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
1
9 BIRTHPLACE
(State or country)
Chelmsford- Marc.
10 NAME OF
Loris F. Hulelande
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Franklin Man.
12 MAIDEN NAME OF MOTHER Jeunic Moram
18 BIRTHPLACE
OF MOTHER
y) Cake Bilin N.B.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Louis to Helland ...
(Address)
20 UNDERTAKER
Walter Fecham
17
| HEREBY CERTIFY that I attended deceased from
mar 2
.. 1917, to
Mar 2, 197,
& OCCUPATION
(a) Trade, profession, or
particular kind of work.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
0
M.D.
mos.
ds ...
....
STANDARD CERTIFICATE OF DEATH.
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, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the sccond statement. Never return "Laborer," "Foreman,""Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no 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: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
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