USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 50
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3. Sudden deaths of persons not disabled by recognized discase, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, cte.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
1 303. G-'18. 50,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County Middlesex
Township No. Chelmsford
.or Village ...
.... or
City
No. 9
hay.
St., ............. .Ward
(If death occurred in a hospital or Institution, give its NAME instead of street and number)
2 FULL NAME
....
Lillian & Green.
(a) Residence.
No
9 gay.
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 hirth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female. White.
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married.
5a If marricd, widowed, or divorced
HUSBAND of
(or) WIFE of
Wilford Green.
6 DATE OF BIRTH (month, day, and year) March, 11, 1891.
7 AGE
Years
Months
-
Days
2/
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work ..
At Home
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
At Home
9 BIRTHPLACE (city or town) ...
(State or country) ·
England
10 NAME OF FATHER
Jonathan Bailey
11 BIRTHPLACE OF FATHER (eity or town) ..
(State or country) .
England
.
12 MAIDEN NAME OF MOTHER Helene Burton Nez, 1918 (Address)
13 BIRTHPLACE OF MOTHER (city or town) ... (State or country) Englands
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? very much worse
Elarney
M.D.
(Signed)
north childArt.
* 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
Riverside Cemetery.
DATE OF BURIAL
Dec, 4, 1918.
(Address)
No. Vb helma ford, Noes.
15 Filed Dec, 3,, 1918 Edward, Y, Rotors REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Dec., 2 1918.
17
latt-sechinees
I HEREBY CERTIFY, That I attended deceased from
Q11. 20
.....
, 1915 to.
, 19 14
that I last saw h LY alive on
and that death occurred, on the date stated above, at 12.05-00
The CAUSE OF DEATH* was as follows :
...... m.
(duration)
.yrs ..!
..... mos.
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
... yrs ................. mos.
ds.
PARENTS
of certificate.
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item 'of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
1918- 2)-
1891.
MARGIN RESERVED FOR BINDING
159 No. Chelmsford. (Citpertown)
State. Mass.
Registered No. 101
14 Wilford Green
Informant
20 UNDERTAKER
GromHealey,
ADDRESS
79 Branch &t
(If in the Army or Navy of the United States, give rank, organization, etc.)
(If non-resident give city or town and State)
27
...
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 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,"' "Dcbility" ("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 hcad - 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.)
Casos 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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
160 Chelmsford
....
(City or town)
Registered No. 102
Township
North Chelmsford
... or Village ...
or
St., .......... .Ward
(If death oeeurred in a hospital or institution, give its NAME instead of street and number)
mary@ Pattern
(a) Residence.
No.
T. Varth Chuchusfard St.
(If in the Army or Navy of the United States, give rank, organization, ete.) .. Ward.
(If non-resident give eity or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Dic/0 19/8.
17
I HEREBY CERTIFY, That I attended deceased from
wee 10
.198
December 5 1918
.. , to
that I last saw h alive on
Dec 10
1906
......
and that death occurred, on the date stated above, at/ 1.15 A
m. The CAUSE OF DEATH* was as follows :
If LESS than
I day, ........ hrs.
or ........ min.
Brescia, poneamena
CONTRIBUTORY
(SECONDARY)
.... (duration)
.yrs ...
........ mos .....
.......... ds.
9 BIRTHPLACE (city or town).
Chelmsford
10 NAME OF FATHER Jonathan Spaulding
11 BIRTHPLACE OF FATHER (city or town) Chebullar (State or eountry) mass
12 MAIDEN NAME OF MOTHER marille. Harwood
13 BIRTHPLACE OF MOTHER (city of town) Chelungund (State or eountry) mass
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
Date of.
Was there an autopsy ?
hard What test confirmed diagnosis ?.
(Signed)
M.D.
, 19(Address) next Chelatill Mais
* 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.)
DATE OF BURIAL 19 PLACE OF BURIAL, CREMATION, OR REMOVAL Hok Hillientry Billerica Dec/3 19/8
20 UNDERTAKER Young & Blake
ADDRESS Lowell
1 PLACE OF DEATH
City
........
2 FULL NAME
(Usual place of abode)
Length of residence in city or town where death occurred
years
3 SEX
Female
4 COLOR OR RACE
what
6 DATE OF BIRTH (month, day, and year)
Years
Months
7 AGE
79
8 OCCUPATION OF DECEASED
D
(a) Trade, profession, or
particular kind of work ..
PARENTS
of certificate.
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
(State or country)
mars
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widow
5a If married, widowed, or divorced
HUSBAND of
(01) WIFE of
Wwwnet. Pattern
Days
7
MARGIN RESERVED FOR BINDING
14 Informant (Address) 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 (b) General nature of industry, business, or establishment in which employed (or employer). (c) Name of employer
County ........................
middlesex
State massachusetts
No ...
....
months
days.
How long in U. S., if of foreign birth ?
years
15 Filed Sec. 12. 1918 Edward & Robban REGISTRAR
(duration)
.. mos .....
7
ds.
... yrs .....
1
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. --- Precise statement of occupa- 's very important, so that the relative healthfulness of various pursuits ean be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fircman, 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) 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 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 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- 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.)
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. 10-'18. 5,000.
------
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
14 Dung O'Neil
Informant
(Address)
East Chelunsford
15
File Dec.16. 1918 Eduard), Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) 200//2018
17 I HEREBY CERTIFY, That I attended deceased from Que 13 1918 to Leup, 16th, 1918
that I last saw her alive on
Dexx. 14th, 1918.
and that death occurred, on the date stated above, at //
119
The CAUSE OF DEATH* was as follows :
If LESS than I day, ........ hrs. or ........ min. Branche . Oricummaria
(duration)
.... mos ........
...... yrs ......
.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)
Hillin 16. Janles
M.D.
16., 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 BURJAL, CREMATION, OR REMOVAL
DATE OF BURIAL
St Patricks Canceling Die 16 9018
20 UNDERTAKER
Geo B. Milena
Jenna
ADDRESS It8 Genham
........
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Mabel Adeline O'neil
2 FULL NAME ...
(If ir. the Arms or Navy of the United States, give rank, organization, etc.)
....
St., ............. Ward.
.......
(If non-resident give eity or town and State)
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female 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)
7 AGE
Years
Months
Days
1
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
None
9 BIRTHPLACE (city or town) ..
(State or country)
напавший
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city or town) Trubel (State or country)
12 MAIDEN NAME OF MOTHER Anna Waters 13 BIRTHPLACE OF MOTHER (city or town) Lowerle (State or country) Massachusetts
The Commonwealth of Massachusetts
16 pl Chelmsford
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF
DEATH'
County .........
Middlesex
State.
Massachusetts Registered No. 11
Township
Chelunsford
City. ......
.. or Villagez .... No. 1606 toliau
.........
St.,
... Ward
(a) Residence.
(Usual place of abode) Length of residence in city or town where death occurred 5 years
months
days.
How long in U. S., if of foreign birth ?
years
months
4 COLOR OR RACE
MARGIN RESERVED FOR BINDING
Chelmsford
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupatien. - 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 line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Groecry; (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 arc 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, 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 None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sareoma, 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 (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," "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 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 de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolie acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (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.)
Casas for the Medical Examiners. Under the provi- Fions 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.
Dr. Varney. oct.
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.
14
Informant
Anthony M. Blackie.
(Address)
Chelmsford, Mase.
15 Filed .. Dec. 16, 2018 Edward Y. Rowling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
Females White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married.
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Andrew B, Blackie
6 DATE OF BIRTH (month, day, and year) July 31. 1834
7 AGE
84
Years
Months
5
Days
14
If LESS than
1 day,
....... brs.
or ........ min.
8 OCCUPATION OF DECEASED .
(a) Trade, profession, or particular kind of work At Home.
(h) 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) Scotland.
10 NAME OF FATHER - Dickinson.
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country) Scotland.
12 MAIDEN NAME OF MOTHER Unknown.
13 BIRTHPLACE OF MOTHER (city or toyn). (State or country) Unknow
16 DATE OF DEATH (month, day, and year) Sec, 15. 19 18.
17
I HEREBY CERTIFY, That I attended deceased from
Sural har darcy this post. 6 much
.. , 19 ..
that I last saw h
._ alive di>
19
and that death occurred, on the date stated above, at
11,55P
.. m.
The CAUSE OF DEATH* was as follows :
Evdo castelo.
1
(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) .
Nek /4 19/ (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 spacc.)
DATE OF BURIAL
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
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