USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 6
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culosis of lungs, meninges, peritonaeum, etc , Carcinoma, Sar- coma, 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 (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease 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," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," "Old age," 36 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 septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions 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, 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.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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
OPLACE OF DEATH
rowell mass
(No.
St. John's Hospital
Robert Daly
? FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.
@RESIDENCE
So, Chelmsford mass
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
' COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word
Single
.......
(Month) (Day)
7 AGE
64
............ yrs.
mos.
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Farmhand
(b) General nature of industry, business, or establishment In which employed (or employer) .......
9 BIRTHPLACE
(State or country)
Unknown
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
1,
12 MAIDEN NAME
OF MOTHER
.
18 BIRTHPLACE
OF MOTHER
(State or country)
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Down of Chelmsford
(Address)
IS Filed Mar. 17 1911 Teffen Flyers REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
march
13
.....
(Month)
(Day)
1911
191
(Year)
HEREBY CERTIFY that I attended deceased from March 7, 1911, to march 13 that I last saw him alive on ....... ......
13
197
and that death occurred, on the date stated above, at / a. m.
The CAUSE OF DEATH* was as follows :
Hyportatio neumonia
1
(Duration)
yrs.
mos. ...
ds.
Contributory ...
(SECONDARY)
{Duration)
yrs.
mos.
ds.
(Signed)
John G. Sweeney
M.D.
Mar 14, 1917 (adress) Dr. John's Hospital
* 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 piace
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
Westlawn Cemetery
DATE OF BURIAL
Mar, 16, 1917
2 UNDERTAKER
ADDRESS
J.F.G. Donnell Sons Lowell
244
Lowell
(City or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
.Ward)
2/ 4757
Registered No.
* DATE OF BIRTH
1873
(Year)
If LESS than
I day ......... hrs.
....
10 NAME OF
FATHER
MARGIN RESERVED FOR BINDING
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- 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," "Dealcr," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ete. Women at home, who are engaged in the duties of the houschold 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 schod or At home. Care should be taken to report specifically 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 indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.
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 discasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal incuingitis") ; Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- meumonia ("Pneumonia," unqualificd, is indefinite) ; Tuher-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, 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 (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease 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," 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 septicaemia," "PUERPERAL peritonitis," ete. 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 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.
1917 1839 18
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH no thelmetal (No. Middlesent St. : .......
.............. .. Ward)
[lf death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Sarah F. Johnson. Enson, Sarah J. Noyes, Julius b. Johnson.
[If married or divorced woman or widow
give maiden name, also name of husband.J
@RESIDENCE
No. Chelmsford
PERSONAL AND STATISTICAL PARTICULARS
[ $ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
. Widowed
23.
18.39.
(Year)
(Day)
If LESS than ( day ......... hrs. or ....... min. ?
.mos.
/ 2x ds
At Home
9 BIRTHPLACE
(State or country)
Lowell Mason
10 NAME OF
FATHER
Graph Noyes
11 BIRTHPLACE
OF FATHER
(State or country)
Bristol U. N.
12 MAIDEN NAME
OF MOTHER
Daptina Queconto
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Brent Johnson,
(Address) Lowell Masa.
Filed
Opis. 6, 1912 Edward LeKobling
- REGISTRAR
MEDICAL CERTIFICATE OF DEATH
...
(Month)
(Day)
191.2.
(Year.
17 I HEREBY CERTIFY that I attended deceased trom abril 2, 1917, to Abril 4
that I last saw him alive on
.......
.. 1917
and that death occurred, on the date stated above, at 5, 3af m.
The CAUSE OF DEATH* was as follows :
Varmcho, precumsonia
S .................. (Duration) ...
.............. yrs.
......
......
mos.
ds.
Contributory ..
chimica brunohule;
....
(SECONDARY)
.... (Duration) ..............
... mos.
.............
ds
(Signed)
JE Varney
M.D.
about 4, 1917 (Address
........
* 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).
In the
At place
of death
... yrs.
.... mos.
ds.
State.
.......... yrs.
............ mos.
Where was disease contracted, If not at place of death ?.
Former or usual residence. ...........
DATE OF BURIAL
19 PLACE OF BURIAL OR REMOVAL Lowell Cemetery April 6, 1917.
20 UNDERTAKER GrothHealey.
| ADDRESS
79 Branch Px.
3 SEX
4 COLOR OR RACE
White .
Females
· DATE OF BIRTH
Feb.
(Month)
TAGE
78
...... yrs.
8 OCCUPATION
(a) Trade, profession, or
(b) General nature of Industry,
business, or establishment in
which employed (or employer).
PARENTS
1ª BIRTHPLACE
OF MOTHER
(State or country)
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
particular kind of work.
At Home.
225 (245) Noch helme {City er town.) .
3
...
....
16 DATE OF DEATH
April
4
Registered No. 22
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 engincer, 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 naturc of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when ncedcd. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Groccry; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Forcman," "Manager," "Dealer," etc., without more precise specification, as Day laborcr, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- Icepers 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 samc accepted term for the same discase. 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- coma, etc., of ......... .. (name origin: "Cancer" is less definite; avoid usc of "Tumor" for malignant ncoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced not be stated unless im- portant. Example: Measles (disease 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," etc.), "Dropsy," "Exhaustion," "Heart failure,". "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL scpticaemia," "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 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.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. Chelmsford St.
: ....... Ward)
(Citron lowny [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Registered No.
23
PERSONAL AND STATISTICAL PARTICULARS
1 SEX
Females
4 COLOR OR RACE
Ahito.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Pingle.
$ DATE OF BIRTH
............... Aug
22.1913
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day ......... hrs.
3 ................ yrs. ......
7 mos.
mos. 22 ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
None.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
None
.. (Duration)
.......
... yrs.
.mos.
10 ds.
9 BIRTHPLACE
(State or country)
Chelmsford, Mass.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Lowell, Mass,
12 MAIDEN NAME
OF MOTHER
Lillian B. Hoodies.
1ª BIRTHPLACE
OF MOTHER
(State or country)
Lowell, Mare
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Frank A. P. Coburn.
(Address)
Chelmsford, Masa
16 File abs. 15, 1917 Edward & Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Abril
/ (Month)
(Day)
13
..... . 1917 (Year,
....
17 I HEREBY CERTIFY that I attended deceased trom 1/2. 3, 1917 to Afer, 12/1997
that I last saw h EL alive on.
Ahir, 12, 197
and that death occurred, on the date stated above, at 6.15 Am.
The CAUSE OF DEATH* was as follows :
Entero colitis
.........
Contributory .. (SECONDARY)
... (Duration).
.... yrs.
mos.
...........
ds.
(Signed)
4/13
1917 (Address).
627 Aymanis
* 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).
In the
At place
of death
yrs
.. mos.
.. 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 Lowell Cemetery
DATE OF BURIAL
Amil 15, 1917
20 UNDERTAKER
ADDRESS
79 Branch 8x
226 6 helmaken afond
Gratia Coburn.
? FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.I
@RESIDENCE
Chelmsford, Maca
...
10 NAME OF
FATHER
Frank Av P. Coburn,
....
M.Q
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 necded. 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 - Goal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housc- kecpers 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 disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic ecrebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinitc); Tuber
culosis of lungs, meninges, pcritonaeum, etc., Carcinoma, Sar- coma, 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 (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease 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," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "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 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.
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 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
(Ho. Chelinford
(No.
Cottage Pour
St. ;.... ............. .... Ward)
( 247) , 227 The Shelfort.
(City or town.) [If death occurred In a hospital or institution, give its NAME Instead of street and number.]
*FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Horth Chehurford ) Has,
PERSONAL AND STATISTICAL PARTICULARS
* SEX
4 COLOR OR RACE
-
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Sich
· DATE OF BIRTH
abril 11 192
(Month)
(Day)
(Year)
I AGE
If LESS than
: day ......... hrs.
... mos. ds. Or ......... min. ?
8 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)
14 Checknofood Hass
PARENTS
12 MAIDEN NAME
OF MOTHER
Dva Haven
13 BIRTHPLACE OF MOTHER (State or country),
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address): Ho Checkshardilla
File April 14, 197, Edward & Pattin
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
1ª DATE OF DEATH
april 13.
(Month)
(Day)
191. (Year)
17 I HEREBY CERTIFY that I attended deceased from april 11, 1917, o april 13, 1917 ....
that I last saw halive on.
amd 13
... .
1917
and that death occurred, on the date stated above, at 30 m
The CAUSE OF DEATH* was as follows :
avenuenhage Jem Stomach
or offer fand o intestino
.. (Duration) .
... yrs.
.. mos.
/
ds.
Contributory ... (SECONDARY)
„(Duration)
............. yrs.
.......
mos.
(Signed)
Fred Elfarmer
afruit, 3, 1917 (Address).
......
NeroChilunden.
M.D
* 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 .
Preside Semetent
DATE OF BURIAL Cubri/ 12/1917
ADDRESS
20 UNDERTAKER Hm H. Jaundias
................................ ....
Registered No.
24
.
.......
...........
10 NAME OF
FATHER
arthur Other
11 BIRTHPLACE OF FATHER (State or country)
...........
important. See instructions on back of certificate.
2
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Frecisc 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 occupation 3 a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, Loeo- 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 cxamples: (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 specifieation, as Day laborer, Farm laborer, Laborer - Coal mine, ctc. Women at home, who arc 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.
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