USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 13
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under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee o11 Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised f ows deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violenee, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
2. Deaths supposedly caused by violenee, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ete.
4. Deaths under eircumstances unknown, as A person found dead, ete.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
Registered No. 39
Township
Chelmsford
...... or Village.
.... or
City .. .No.
St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number) Sims (Infant)
2 FULL NAME.
(L'ir the Army or Navy of the United states, give rank, organization, etc.)"
(a) Residence. No. Chelmsford Inas St.
.. Ward.
(Usual placc of abode)
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Female
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year) May 25,1919
7 AGE Years
Months
Days /
If LESS than 1 day .......... hırs. or ........ min.
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
.
9 BIRTHPLACE (city or town).
(State or country)
Chelmsford
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
12 MAIDEN NAME OF MOTHER Makel Sime
Lowell
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
mar
14 mrs. Solo Sving.
Informant
(Address)
Chelmsford
15 Filed June 2, 1919 Edwards Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
May 2 6 1919
17 I HEREBY CERTIFY, That I attended deceased from may 25 1919 to May 26 1919
that I last saw her alive on
may 26
., 1919
4-451.
and that death occurred, on the date stated above, at
.. m.
The CAUSE OF DEATH* was as follows :
Traumatic Inverser de Brains
..... following frech delivery
(duration)
... yrs ...
... mos ...
1 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 ?..
5 (Signed)
James y. Rodger
M.D.
27, 1999 (Adress) Could Mars
* 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 spaec.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Pine Ridge 6
DATE OF BURIAL
May 28, 199
ADDRESS
20 UNDERTAKER
Walter Verham
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.
1 PLACE OF DEATH middlesex County.
State
Maser
,2040 Chelinford
(If non-resident give city or town and State)
DEVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
....... . .......- 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 terin on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architcet, 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 samc 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; Chronie 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," "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," ctc. 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.)
Cases 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, ctc.
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. 1-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH)
County.
Middlesex
State
mass.
Registered No. 40
Township
no. Chelmsford
.or Village
.... or
City No ....
St., ......... .Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME ..
marie Blanche Boucher
..... "(tffrrthe-fri of Navy of the United States;give rank; organization, etc.)-
(a) Residence. No. (Usual place of abode)
Length of residence in city or town where death occurred years 11 months
days.
How long in U. S., if of foreign birth ?
years
months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX female
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Singh
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
June 4, 1917
7 AGE Years
Months
Days
If LESS than I day, ........ hrs. or ........ min.
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 ·
9 BIRTHPLACE (city or town).
720. Chelmsford
(State or country)
10 NAME OF FATHER Philias Boucher
11 BIRTHPLACE OF FATHER (city or town) St. Johnshan (State or country) 24 .
12 MAIDEN NAME OF MOTHER Filia Levasseur
13 BIRTHPLACE OF MOTHER (city or tewn) Lewiston (State or country) me
14
Informant
(Address) no. Chelmsford
15 Filed May 29, 1919 Edward 9. Bobby
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
may 28, 1919
17 I HEREBY CERTIFY, That I attended deceased from
19 ..
to.
May 27, 1919
that I last saw her alive on
May 27 1919
and that death occurred, on the date stated above, at
1 P-
... m.
The CAUSE OF DEATH* was as follows :
Whooping Cough
0
.. (duration)
1
.mos ..
ds.
CONTRIBUTORY.
Cerebral involvert
(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 ?.. fixed & Van
5 (Signed)
.....
& & Phillips
.,
M.D.
28, 19/9 (Address) 200. Cheffor Dy
Kor
mars
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (I) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL St. Hansford has
DATE OF BURIAL
May 29, 2019
ADDRESS
20 UNDERTAKER
borgh albut
Bonall
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.
PARENTS
1
Ward.
(If non-resident give city or town and State)
205 Chefingford (City or town)
... yrs ...
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Censes and American Public Health Association]
Statement of occupation. - Precise statement of oecupa- tion is very important, so that the relative healthfulucss 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, Architcet, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, espceially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and thereforc 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 "Laborcr," "Foreman," "Manager," "Dcaler," 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 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 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 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 affcetion with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (thc only definite synonym is "Epidemie 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., Careinoma, 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 symptomatie), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con- genital," "Senilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shoek," "Uremia," "Weakness," cte., when a definite disease can be aseertained 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 (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Rccommendations on statement of eause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referr ... .. the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, cte.
2. Deaths supposedly eauscd by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ete.
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. 1-'18. 100,000.
MARGIN RESERVED FOR BINDING
3 SEX Female PARENTS carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, 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 particular kind of work.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
............
(City or town) Registered No. 41 ....
Township
Lowall
.. or Village< Lorvill Sevil Hospital ..... or
St., .. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Louise Miller
(a) Residence.
No
No. Chelmsford Mass.
.. Ward.
(If non-resident give city or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
May 30, 1919
17
I HEREBY CERTIFY, That I attended deceased from
may 1
,1919 to
May 30, 1917.
that I last saw her alive on
Many 30 1919
.......... and that death occurred, on the date stated above, at 10-a The CAUSE OF DEATH* was as follows :
..... m.
7 AGE
57
Years
Months
4
Days
27
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
at Home
(b) General mature of industry, business, or establishment in which employed (or employer) ... (c) Name of employer
9 BIRTHPLACE (city or town) ..
Brookfield
(State or country)
Ot.
10 NAME OF FATHER ,
mouse
Brookfield
11 BIRTHPLACE OF FATHER (eity or town).
(State or country)
2
5 (Signed).
Thomas forland
12 MAIDEN NAME OF MOTHER Orvilla Walker
13 BIRTHPLACE OF MOTHER (eity or town) ....
(State or country)
mass
14 Thursband
Informant
(Address) 720, Chelash
15 Filed Jeme 6, 1919 Edward le potom REGISTRAR
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 ?
M.D.
31, 19 /9 (Address) Lowell Deal Harfital
* State the DISEASE CAUSING DEATHI, 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.)
DATE OF BURIAL
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
modelar
Cem,
mais
ADDRESS
20 UNDERTAKER
I S. Blown
206 Chechueford
1 PLACE OF DEATH
County Middlesex
State. mass
City ..
No.
(Usual place of abode)
Length of residence in city or town where death occurred
years
/
months 14
days.
How long in U. S., if of foreign birth ?
years
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
John F. miller
6 DATE OF BIRTH (month, day, and year)
Jan, 2, 1862
If LESS than 1 day, ........ hrs. or ........ min. Cancer de Livres Lung
& mesentery
.. (duration)
1
.yrs ...
..... mos ..
11 ds.
CONTRIBUTORY
(SECONDARY)
.. (duration)
.... yrs ...
......
... mos .............
ds.
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Apmoved by U. S. Census and American Public Health Association]
. Pronice statement of occupa -.
cach and every person, irrespective of age. For many oceupations 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) Grocery; (a) Forcman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dcaler," etc., without more precise specification, as Day laborcr, Farm laborer, Laborer - Coal mine, ete. 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 oeeupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, ete. 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- catcd 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 samc disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie 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, ete., of ..
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease eausing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Ancmia" (merely symptomatic), "Atrophy," "Col- lapsc," "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 asecrtained as the cause. Always qualify all diseases resulting from child- birth or misearriage, 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- terminc 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., 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.)
Cases 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 Medieal 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, 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 eircumstanees unknown, as A person found dead, ete.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS
BY
PHYSICIAN.
R 15. 1-'18. 10,000.
FORM R-301
MARGIN RESERVED FOR BINDING
3 SEX male 4 COLOR OR RACE what 5a If married, widowed, or divorced HUSBAND of (or) WIFE of Yoars /00 Month) 7 AGE 57 If STILLBORN, enter that fact here 8 OCCUPATION OF DECEASED (a) Trade. profession, or particular kind of work .... (h) Generai nature of industry, business, or establishment in which employed ( or employer). (c) Name of employer 11 BIRTHPLACE OF FATHER (City). (State or country) 12 MAIDEN NAME OF MOTHER PARENTS Informant (Address) in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information instructions and extracts from the laws on back of certificate. should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH If STILLBORN, state period of uterogestation. mos.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
manrua
6 DATE OF BIRTH
July 29-1861
(Day)
( Year)
Months Days
If LESS than
1 day, ........ brs.
or ........ min.
Petere 2
9 BIRTHPLACE (City)
BlueZiel
(State or country) mais
10 NAME OF
FATHER
Theodore Stevens
manz
murati Hanskluge
13 BIRTHPLACE OF MOTHER (City) (State or country) Imamz
14 Le guia Stevens
15 June 3, 1919 Edward, Robbins (Month) (Day) (Year)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me Godward & Pething BEFORE the burial or traosit permit was issued
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
June
2 nd
- 1919
(Year)
(Day)
17
I HEREBY CERTIFY, That I attended deceased from
May 12
1919, to June 2
.. 1919
that I last saw h/w alive on
....
N
, 1919.
and that death occurred, on the date stated above, at YP
...... m. The CAUSE OF DEATH was as follows : -
asthenic Bulbo-Spinal Paralysis
about (duration) ..... 3
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? no ..... Date of ..........
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