USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 8
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Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51
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.
i
R. 15-8-'15. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
....
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX wall what's
6 DATE OF BIRTH
(Month) (Day)
7 AGE
If LESS than 1 day, ........ hrs.
.... yrs.
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 employers
desprender will
9 BIRTHPLACE (State or country) Middleton
10 NAME OF FATHER
Michael J & gan
PARENTS
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country) Lulang
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informan Edna AIligan WE
(Address) Jellet full mark
15
Filed Muna 14, 191) Oderand Rollng
REGISTRAR
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : Прико208от 8мм. многиты
Said Whale fall us in filling out of
au au tomobil -
.(Duration) ... yrs. mos.
ds.
Contributory .. (SECONDARY)
mos. ds.
(Signed)
May 14
1917 (Address).
M.D.
/ MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
In the
of death yrs.
mos.
ds.
State ............ yrs.
.mos.
ds.
....
Where was disease contracted, If not at place of death ?.
Former or usual residense.
19 PLACE OF BURIAL OR TEMATEM ownson
huddletown Coun
/
DATE OF BURIAL may/697
20 UNDERTAKER
ADDRESS
-
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE mutton
Registered No. 28
MEDICAL CERTIFICATE OF DEATH
Y DATE OF DEATH
May
12
(Month)
(Day)
191. ( Year)
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
PLACE OF DEATH Chelmsford
(No.
St. Ward)
4 COLOR OR RACE 5 SINGLE MARRIED
WIDOWED
OR DIVORCED
1 (Year)
J. J. ODonel Sons 3
important. See instructions on back of certificate.
11 BIRTHPLACE OF FATHER (State or country)
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 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) Groccry; (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 reccive 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 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, meninge.
", BUT-
coma, 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 (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," "Collapsc," "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. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine 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."
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 16. 11.'16. 5,000.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
APLACE OF DEATH North Chelmsford " FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE J SEX 4 COLOR OR RACE 5 SINGLE MARRIED. WIDOWED, OR DIVORCED (Write the word) Male White · DATE OF BIRTH (Month) (Day) ' AGE 67 (b) General nature of industry, business, or establishment in which employed (or employer) ... PARENTS 18 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 ... ......................... yrs. .. mos. ..... ds.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
....
Gay
St. ;.... ................... Ward)
(City or town.) Tif death occurred in a hospital or institution, give its NAME Instead of street and number.]
pred 1. Duncan
North Chelmsford
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
Manid
-
(Year)
If LESS than
1 day .......... hrs.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
Master Mechanic
9 BIRTHPLACE
(State or country) -
Hancock U.H.
10 NAME OF
FATHER
Nathaniel . Dunca
11 BIRTHPLACE OF FATHER (State or country) Hancock 4.76.
12 MAIDEN NAME
OF MOTHER
Francis M. Taylor
Bennington 471.
14 THE ABOVE IS-TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Augustus S. Duncan
(Address)
Www. Chelmsford
16 Filed May 14, 197Edward Shuffling REGISTRAR
.......
...
(Month)
(Day)
1917
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Mich 11
.. 1917, to
May 12
1917
that I last saw h alive on.
May 12
and that death occurred, on the date stated above, at 10:30 Pm The CAUSE OF DEATH* was as follows :
Cystitis (suplee)
(Duration)
3
.yrs.
mos.
ds.
Contributory ... (SECONDARY)
.(Duration).
............ yrs. ..
. ................ mos.
ds
Fred & Carry
M.D
May 13, 1917 (Address).
Horttehlikel
....
* 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 ..
... mos ..
.ds.
State ....
............ YTs,
....
Where was disease contracted,
If not at place of death ?....
Former or usual residence ...
19 PLACE OF BURIAL OR REMOVE KILMAMALE OF BURIAL
Quanside Remitir May 14, 1917
UNDERTAKER Dinimons + Brown will.
4
Chelmsford eford
29
MEDICAL CERTIFICATE OF DEATH
1ª DATE OF DEATH
May
13
12
. ?
.....
TARA
STANDARD - OF DEATH.
ULII ...
Statement of occupation. - Precisc 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 cngincer, 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 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," ete., 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 serviec 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 (rctired, 6 yrs.). For persons who liave 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 "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lun
.
coma, etc ·ncer" is less
definite; avoid use of "Tumor" for malignant ncoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ctc. 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- acmia" (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," 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.
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
howell mass
.(No
LA. John's Hospital.
.... St+ ; Ward)
Smith
30
822
PERSONAL AND STATISTICAL PARTICULARS
1 SEX
male
-
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
Widower
194
17
(Year)
" AGE
If LESS than
1 day ........ hrs.
1 m
.mos. ....
280.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
none
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE
(State or country]
" new Hampshire
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country}
new Hampshire
12 MAIDEN NAME
OF MOTHER
Susan Eastman
1ª BIRTHPLACE
OF MOTHER
(State or country) new Hampshire
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
mra Cora BRulta
(Address)
Chelmsford mass
Filed may 18, 191. ........... REGISTRAR
=
P MEDICAL CERTIFICATE OF DEATH
17
1911
.....
(Month)
(Day)
.......
(Year)
I HEREBY CERTIFY that I attended deceased from
may
1
.......
1916, to May 152
191
that I last saw bern) alive on.
44
150 191.
and that death occurred, on the date stated above, at Ja.m.
The CAUSE OF DEATH* was as follows :
Broncho -
Pneumonia
( Primary
(Duration) .... ).
yrs.
.......
mos
... ds.
Contributory Myocardial De generation
(SLCONDARY)
... (Duration)
...........
........ mos.
...............
... ds.
(Signed)
May 16, 1917 (Ad
16.
arthur & cobora M.D.
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.
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
Edson Cemetery
DATE OF BURIAL
May 18, 19
ADDRESS
20 UNDERTAKER Simmons + Brown Lowell
Lowell
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
l'on A woman
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.1
@RESIDENCE
8. Chelmsford mais
Registered No.
$ DATE OF BIRTH
march
17
(Month)
(Day)
16 DATE OF DEATH
may
16
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
10 NAME OF
FATHER
William Smith
am
Sar-
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be kuown. 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," ctc., 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 busiucss, 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 disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (uever ro- port "Typhoid purumonia"); Lobar pneumonia; Bronche- mmeumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
„(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignaut 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," "Scnilc," 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 persous not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc
4. Deaths under circumstanecs unknown, as A person found dead, etc.
R IS. 3-'16. 10,000.
.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
..... 3 SEX 7! 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
1 PLACE OF DEATH Chelmsford (No. Doston Road
Chelmsford 6 (City or town.) ... Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
2FULL NAME Barbara renner
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford.
Milliano, Bremner
Registered No.
3/
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
may
23
(Month)
L
(Day)
1917
(Year)
· DATE OF BIRTH
Aug
30
18.38
(Month)
(Day)
(Year)
TAGE
78.8
.mos.
23
ds.
.... yrs.
or ......... min, ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
at some
(b) General nature of industry, business, or establishment in which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Scotland
10 NAME OF
FATHER
James Crail
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
Magdalena Batteron
13 BIRTHPLACE
OF MOTHER
(State or country)
Scotland
Where was disease contracted, If not at place of death ?... .... Former or usual residence. .........
19 PLACE OF BURIAL OR REMOVAL
Forefathers Cen.
DATE OF BURIAL
May 26
1917
(Address)
Chellesfinal mases
15
Filed
May 26, 199 7 adrined & Robbing
REGISTRAR
* 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 ...
......
....
ds.
Contributory ..
(SECONDARY)
.. (Duration)
.yrs.
.......
mos.
ds.
(Signed)
Antru J. Icoloria.
M.D.
May 2 6, 1957 (Address).
Chilis dan, mass.
/
...
about brukes -
.. (Duration) ................ yrs.
................ mos.
.......
......
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Nro. Beuf Cole( dangluten)
7
St. ; .................... Ward)
4 COLOR OR RACE
w
-
5 SINGL
MARR
WIDO
OR DIVORCED Low
( White the word)
-..
If LESS than
1 day, ........ hrs.
17 I HEREBY CERTIFY that I attended deceased from apr. 14. .. 1917, to. Thay 16, 1917 .... that I last saw h fa alive on may/16, 197 and that death occurred, on the date stated above, at a.m. The CAUSE OF DEATH* was as follows :
............................... Left himifinin. 0
ADDRESS
Walter Perkam Chelmsford
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 laborcr, Farm laborer, Laborer - Coal 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 employcd, 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 (rctired, 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 cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber .
definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ctc. 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," "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.
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