USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 7
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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, ctc., Careinoma, 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 .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the causc. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieaemia," "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.
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
I PLACE OF DEATH
So Chelimitan & mas.
St. :
..... ................. Ward)
(City or town.) [If deeth occurred in a hospitel or institution, give its NAME instead of street and number.]
2FULL NAME
accélie lamon
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
accedimarin- Pierre Gagnon
Sr. Chelmsford
Registered No.
2,5
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
apr.
20
(Month)
(Day)
1917
(Year)
* DATE OF BIRTH
July
(Month )
(Day)
(Year)
* AGE
65 Vb.
7
............. yrs.
... mos.
15
If LESS than
1 day ......... hrs.
¡ds.
or ........ min. ?
& OCCUPATION
(a) Trede, profession, or
particular kind of work.
Homme
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Canada
10 NAME OF
FATHER
Christopher Marin
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Canada.
12 MAIDEN NAME
OF MOTHER
MOTHERnice Parain
18 BIRTHPLACE
OF MOTHER
(State or country)
Canada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
mis Warren Wright.
(Address)
so. Chelmsford
16
File Apr. 23, 1917 Edward A Robbing
REGISTRAR
1 HEREBY CERTIFY that I attended deceased from
1916, to
apr. 20
., 1917
that i last saw he alive on.
apr 20
about
.... ,
1917
and that death occurred, on the date stated above, at 6
... m
The CAUSE OF DEATH* was as follows :
hurcordial argeneration
1
... (Duration) .
............ yrs.
.......
mos.
....
ds.
Contributory
(SECONDARY)
(Signed)
Artur
............. yrs. .........
. mos.
................
Ocoborca
... .
M.Dy
apr. 21 1917 (Address).
Chelmsford, mais.
.............
* 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 ...
. ............
In the
..... mos.
ds ...
............
..............
............ yrs.
.......
Where was disease contracted, if not at place of death ?...
Former or usual residence. ....
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Cpu 23. 1917.
20 UNDERTAKER
Pawel
ADDRESS
17/ Ciklas
3 SEX
4 COLOR OR RACE
W
15 SINGLE
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
married
1848 12
228 (248)
.
......
....
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 enginecr, 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 disease. Examples: Cerebro-spinal fcvcr (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) ; Tubex
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 heed 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" (mcrely 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," 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, ctc.
1
a
adama Caroline S. aller Lamise a
adam Charles E.
adama Willard a. 237 Brown
Adam Charles 2
242 Bennet Raymond 6. 48
Bartlett mallard
53
Bu dyer Henry 8. 55
Bontwatt Marie avis 7/
J
Baker melican 2. 77
Barber James E. 90 Burchell Hinnifeed & 94
Byam Damil P.
101
M
Barlow
Brault Ernest .
Boothby Levi
Balser Sharks &
213 Brault Clara
128
Boucher Claire
129
Bonney (Stillborn) 137
Boise Josephine 245
Bartlett Charlotte a.
249 Bonney Elcanon W. 142
Brown Isabella ). 1476
Blackie margaret 162
Bairstow Emma a. 172
Barretow Enuna a. 174 Bishof Corthu 188 Bancroft Sarah 6. 202
Y
Z
Boucher Marie B
205
A B
6 C D
156 Barlow Harold
227 Byar .. marietta 23 E
43 F
G H I
K L
N 0 P Q R S T D V W
211 Billkowski Joseph
123 605
Buntel Jennie m. 238
122
B. Continued
03
64 Brenner Barbara
Communique Hilliard 6. bookem aliceM.
black Elizabeth &.
Clawson Christopher To. 84
Corcoran Mary 87
Chamberlin Wilbur Fr.
Colburn & Henry
Champagne Edmond N
78 Dennegan Charles 57 Di Palma Philomena menes 66 Aziedulonis andriena 92
: 15:1 Dearth Emilia 6.
110
196 Duffy William 119.
214 Devlin James 136
Dunn mary I
139
Ducharme Timeline C.
154
Dixon Elizabeth
163
Douglas alice 16
165
Duckworth George 170 Donohue may 178
Denault Olive 194 Derbyshire Lizzie 6 200
Day Francia 247
-
1 .
30 Duncan Fred T. 4
56 Dubois Victoria
Gowan Lovina 72 Davis Joshua F. 41
1
Eduarda Davina M. 61
Ellis arthur G. 115 Ellicte John 2. 131
Figure Oliva 10
Fiche Elizabeth a.
46
Fiche - -
62 E
terron Marie 2.
69 F
Fullerton maya. 7/ G
Fecteau Odevir 2. 95
Fletcher arthur F. 147
Fletcher William H. 175
Foster Sarah In.
190
Flanders Charles H. 203 Farrow Thomas B. 215
Fleming Blanche 71. 233
-
M N 0 P Q R S T U
V W Y Z
H I J K
L
Grant Sandette marie Gagnon
28
Harrison Bible 2 45 Holland Eller 22 68 Harrard John a. S. 24 Haley Roce &. 26
Gagnon mitchel
? 881
Gandette Gilbert E.
Greene Lydia a.
Grenier maria
Green Charles 140
Gumb Sarah am
Green Lillian & 159
Goodwin annette
Green Julia ann
Gallardetz agnes
Sladn Paul H. 224
Holdeworth
9€
Haley arthur J.
98
Hodgman Benjamin 132
HowE Edwin . 141
Holt Lama G. 164
Hibbert Lizzie F. 169
Hanson augusta 181
Hocking Many a. 199
Helliwill mary 208
Hartchom Florence S. 212 Hines William 228 Haley Douglas 230
Hanley annie 248
100 Kullander Richard 8. 82
105 Holgate John 37 Holt Leauge B. 125 38 Habo Rama H 42
149 Hoyt Nm. a.
70
Hamblett Cyrus 75
167 House Char H. 79
217 Howard adominar 85
21.8 Hegarty mary &
93
Ingham nancy 71. Ingalls John P. 222
Ingalls agnes 2. 225
Jatkowski Peter Johnson Decar It 231
6
179
I J K L M N 0
P
Q R S T U V W Y Z
K
Knox John Know Robert m. Konlas alexander Ridder Pauline H. Kelley
Kane margaret
15 Lechin Sieme M.
46 Lachance Poranna 107 50. Lamphere Berge B. 12]
166 Lavil. Kter & 144 221 Lyons anna I. 153
2.39 Full Caroling 6. 155
Logan Thurlow M. 187 Le masurier 192.
Laline alphonse 210 Liebedzinski Joseph 216
Lear John 229
McDonald James 1. Mercia William
molloy
mollon
more Jessica R.
Marinel Harrison L. 89 11,8
monroe many m.G.
123
Mc Enaway Sylvester H. 76
HEnancy mary J. 135
If Comb
150
mcDonald Ellen 1.68
DiManomin John For 1.93
Mooney Thomas a. 195 Mac naughton Catherine 3. 198 miller honice 206
Mayor Josephine a. 220 Mc Enany John H. 232
moore Wendall C.
235
Inc martes Searge. 236
McDonald alexander 243 miller John & 250 marton 251
1
25 Nagler Samuel 1 :33 Tickles Richmond 8. 20
51 Mardin Herman. a. 29 52 Dreault Jane 35
76 nickler addie S. 86 nickles Elizabeth &3. 114
M N 0 P Q R S T U V W Y Z
Okoki Kin Ohlson Da Dr. Meil Mall a. Olezon John
21.
Chinkest Thomas: 12.
1543 Perfram Estelle. S. 13 161 Porter & annette 14
219 Profis - - 54
Primí Elgrar 58
Perry Large 6/
Parker Ella m.
73.
Patenan de albert 81
Gabhunt Edith M. 812
Patterson Char. Fr
83
Perham Harriet In
133
Patten Mary P. 160
Perham David 223
Parkhurst Clourida H. 226
Darks 240
Packs Grace 241
Vicard Ernest 246
- Iwill albert Quinn John P. Juist Regina 2.
:
166 Vegan Skilliana 3 130 Richardson Lyman! Began Bridget 182 17 Roberts Proctor a. 11.4. Robinson Charles a. 17
Rouleau June 60
Robage marie 2. 74
Rondeau Joseph P.
109
Robinson Thomas
148
Richardson Hubert H. 158
Roy Honore 173
Rondeau 186
Podie Henry 234
Richards Steffen.
244
Q R S T U V W
Y Z
S
Smith Thomas Sthores - - - Spaulding George Sawyer Jeantha Skritch nicholas
Sartori Egidio Spaulding Lydia a. Sermon 6 devar d
Stetson Jenas . Stafford John Sherlock Oven
Strandberg Harry O.
138
Suttle George
180
Sheehan Kellie For. 197
Simmer 204
Stevena Clarame 6. 207 Sanford Luther 209
5- Thompson Fanny W. 65
34 Vitcon Luther 6. 1.03 12/2
36 Trambley Jule 39 Vaylon albert 134
49 Vanery Catherine & 145 97 Graverey John R. 177 99 Uyler mary 2. 3. 179
103 Grites Mary a. 184
10k Valles S. Lavina 185 108 Waylon Martin 201
/26
159
Valentine mary E. Vickery Hattie & 189
U
V W
Y
Z
y
Walker Donald 8
Holch annie B.
Winning Hazel &.
18
Hacker William 71. 19
Whitcomb Celica &
3/
Williams Rose 2.
59
Webster Eva Fr. 63
Wilson Catherine 111
Wilson George a. 112
Wilson Square 116
Falsch Michael 152
Whitney Halter 13 157
Walker abbie & 176
Hatton Ellen B. 183
Williamson Charles Mr 191
-
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.
1 PLACE OF DEATH
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
West Chelmsford
(City or town.)
{If death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
Servel Yerler
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
West Chelmsford Mass
Registered No. 26
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
White
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Tarriel
6 DATE OF BIRTH
(Month)
(Day)
.. (Year)
7 AGE
If LESS than
I day ......... hrs.
Or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
Sal .Sen
particular kind of work
(b) General nature of industry, business, or establishment In which employed (or employer) ...
biff. after abdominal seguro
(Duration) ..
1
.... yrs.
.mos. ... ... ds.
Contributory ...
(SECONDARY)
(Duration).
............. yrs.
...........
... mos.
ds.
(Signed)
7 EVarney
M.D.
May 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).
At place
of death
.. yrs.
In the
.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 West Chelmsford Y ss
DATE OF BURIAL
Nay E
191
16 Filed May 5, 1917 Edward YR Ning
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Hav 4 2077
191.
....
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Le13
1916 to
July 6
..
1917
that I last saw him alive on.
,
1917
and that death occurred, on the date stated above, at & c.m.
The CAUSE OF DEATH* was as follows :
Cancunconca
9 BIRTHPLACE
(State or country)
Englan 1
PARENTS
10 NAME OF
FATHER
Tobeph Taylor
11 BIRTHPLACE
OF FATHER
(State or country)
EnImal
12 MAIDEN NAME
OF MOTHER
Ponnah Rimley
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Hey My. Taylor
(Address) Was+ Chelmsford Masa
.......
4
St. ;.................... Ward)
20 UNDERTAKER You got Blake
ADDRESS
33 (Thescarf
............
MARGIN RESERVED FOR BINDING
... yrs. .... ... mos. ds.
1
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 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) 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 dutics 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 betaken 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- BASE 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, 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," "Hacmorrhage,", "Inanition,". "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all Aiseases 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, ete.
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 strect, or onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15-8-'15. 100,000.
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.
(Informant)
Jana: H. Harrison
(Address) Worth Melnsfort
16 File May 10, 1917 Edward ) Robbins
.....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
Lav 9 1917
(Month)
(Day)
191
(Year)
· DATE OF BIRTH
July
18 18
(Month)
(Day)
₱
(Year)
68. yrs. 70 mos. ds. or ......... min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment In which employed (or employer) ...
O BIRTHPLACE
(State or country)
10 NAME OF FATHER Not Known
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER 11
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Edson Cembery
DATE OF BURIAL
May 10
7
191
20 UNDERTAKER Young 811 Blake
ADDRESS
33 VuecostLx.
.... 3 SEX Tral? 7 AGE PARENTS 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
North Chelmsford
Worth Chelmsford
.(No
St. :..
Ward)
.............. ...
(City or town.) [If death occurred in a hospital or instituticn, give its NAME instead of street and number.]
2 FULL NAME
Relle Harrison
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
...............
....
Registered No.
27
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Tarried
......
17 I HEREBY CERTIFY that I attended deceased from May 5, 1917, to ......... .......
heavy.
.....
.18
........ , .... 1917, and that death occurred, on the date stated above, at/a.m. The CAUSE OF DEATH# was as follows :
Diabetes
7
.. (Duration).
..... yrs.
.. mos.
ds.
Contributory.
Thronessofresse/ rgangrace 1 Rfax
(SECONDARY)
.(Duration)
.yrs.
.mos.
(Signed)
Marshall & Alleine
may 10, 1917 (Address) Forell, Mas.
* 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.
Where was disease contracted, If not at place of death ?.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
4 COLOR OR RACE
White
1
If LESS than
1 day ......... hrs.
hay 9, 1917
that I last saw her alive on.
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 engincer, Civil engineer, Stationary fircman, ctc. 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," "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 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- BASE 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 nys, 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 bo 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," ctc.), "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 Aiseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia,", "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
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