USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 3
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(name origin; "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (secondary or inter- current) affcetion need not be stated unless important. Example: Measles (discase causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mcrc symp- toms or terminal conditions, such as "Asthenia," "Anemia" (increly symptomatie), "Atrophy," "Col- lapse," "Coma," ""Convulsions,"""Debility" ("Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shoek," " ""Uremia," "Wcakness," cte., when a definite disease can be asecrtaincd as the eause. Always qualify all discases resulting from child- birtli 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- 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 fraeture of skull, and consequences (e. g., sepsis, tetanus) may be stated
"der the head of "Contributory." (Recommendations of eausc of death approved by Committee on Nomenelature of the Aincriean Medical Association.)
Cases for the Medical 5. the provi- sions of chapter 24 of the que viocu wawa ucauns under the following conditions must be referred to the Mcdieal Examiners:
1. Deaths following injury or violence, as Burns, Falls Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly eaused by violenec, 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, ete.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 303. 6-'18. 50,000.
172
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
1 PLACE OF DEATH
County ..........
middlesex
State maas.
Registered No.
8
(Place of residence)
St.,
. Ward
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
(a) Residence.
State
mass
City or Towa halmekord.No
St.
(Usual place of abode)
Length of residence in city or town where death occurred
90
years
months
days
How long in U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Necidowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
8 lie Descheme
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
79
Months
Days
If LESS than
1 day, ........ brs.
or ....... min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work ..
Woodchopper
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
.. (duration).
yrs.
.. mos.
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
.yrs. ...
mos.
ds.
10 NAME OF FATHER Jean 10
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?.
Date of_
Was there an autopsy ?.
What test confirmed diagnosis ?.
(Signed)
9. 8 Caisse
M.D.
14
Informant ......
Itanace Roy fre
(Address)
98 Jinaker ISA
15
Filed Jan 221919
En. legistar of city pr town where death occurred Filed tel. 11 19 19-9
Registrar of cite/or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) , 19
1919
17
I HEREBY CERTIFY,
That i attended deceased from
19
to kan. 19
....
that I last saw heram alive on
19, 1919 ..
and that death occurred, on the date stated above, at 840 ..... m. The CAUSE OF DEATH* was as follows :
*State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.) Chronic Vale Diorang of Heart
9 BIRTHPLACE (city or towort bande marthe (State or country) chamada
PARENTS
11 BIRTHPLACE OF FATHER (city or townet Thous (State or country) Canada
12 MAIDEN NAME OF MOTHER Untenor
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
Canada
1-20 19 19 ( Address)
Sowell
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
St. Joseph Cemetery Jan. 2/19/9
20 UNDERTAKER J. albert
ADDRESS Lowell
-
Registered No ...
( City or town )
174
........
(Place of death )
City or Town.
Lowell
No. 98 Jucker
og
(If inthe Army or Navy of the United States, give rank, organization, etc.)
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 statoment 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
FASCI FRITID STATES STAND ... . .
[Approved by U. S. Census and American Public :! :
Statement of occupation. - Pr .
tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive 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 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) Salcsman, (b) Grocery; (a) Forcman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," " "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer; Farm laborer, Laborer -Coal minc, 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, Houscwork, or At home, and children, not gainfully employed, as At school or At homc. 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 Nonc.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATII (the primary affection with respect to tine and causation), using always the same accepted terni for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoul fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, etc., of_
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Mcasles (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 eausc. Always qualify all discases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoncd by carbolic acid - probably suicide." The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
BIUNS Of chapter 24 Of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism., etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R$ 303. 6-'18. 50,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or >own)
Registered No. 10
Township
Chelmsford
.or Village.
.... or
City
No.
... ,
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
William Henry Fletcher
(a) Residence.
No.
Chelmsford/
St.,
........
.. Ward.
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year) May 28 1918
7 AGE Years
Months
Days
6
If LESS than I day, ........ brs. 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
CONTRIBUTORY (SECONDARY)
(duration)
.. yrs ....
... mos ..
ds.
9 BIRTHPLACE (city or town)
Chelmsford
(State or country)
10 NAME OF FATHER Walter S-Fletcher
PARENTS
11 BIRTHPLACE OF FATHER (city or town).
Medfild
(State or country) masa
12 MAIDEN NAME OF MOTHER Esther allen
13 BIRTHPLACE OF MOTHER (city or town) Frale (State or country)
14 M.S. Fletcher
Informant
(Address)
Chelmsford
15 File d. Feb. 5, 1919 Edward Ju Robbing REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Eden Com Sowell
DATE OF BURIAL Het 5 1919
20 UNDERTAKER
Walter Perham
ADDRESS Chelmsford
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.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Feb. 3 1919.
17
I HEREBY CERTIFY, That I attended deceased from
Jan. 30,
, 1919, to Fnb 3, 1919.
/
that I last saw h ...
alive on
19
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows :
(duration)
.. yrs.
mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death? NO. Date of.
Was there an autopsy ?.
20.
What test confirmed diagnosis?
(Signed).
Anthus 1. Scolaria
, Ml.D.
2-25,19 /C (Address)
* State the DISEASE CAUSING DEATH, Op 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.)
175 Chelmsford ....
1 PLACE OF DEATH
County.
Middlecen
State.
St ..
Ward
. ........
(If non-resident give city or town and State)
m.
TIPARD CERTIFICATE OF DEATH a Pal" Health Association
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, Architeet, 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 homc, 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. It 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 tinic and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronehopneumonia ("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; Chronie interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 &s .; Broneho- 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- inus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all discascs 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, Of HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - nomicide; Poisoned by earbolie 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 "Cont
vions
on statement of caus
.nmittee -
on Nomenclature of
ociation.)
Casos for the Me
the provi-
of chapter ^
:33 imder the
following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ctc.
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
................
(City or town) Registered No. 11
1 PLACE OF DEATH
County ..
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)
2 FULL NAME
abbie Ellen Walker
(If in the Army or Navy of the United States, give rank, organization, ete.)
(a) Residence.
No.
Chelmsford
St.,
.Ward.
(If non-resident give eity or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divewu-d
HUSBAND of
(or) WIFE of
Melvin Mallar
6 DATE OF BIRTH (month, day, and year) Och 13 1851
Years
Months
3
Days
22
If LESS than
I day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Housewife
(b) Genera'l mature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (eity or town).
Mt. Vernon
18 Where was disease contracted
if not at place of death?
X
Did an operation precede death? 20. Date of X
Was there an autopsy ?.
no.
What test confirmed diagnosis? physical Symptoms
(Signed)
Umasa Howard
M.D.
2/9, 199 (Address)
Chelmsford Mass.
* 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 spaee.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Pine Ridge Com.
DATE OF BURIAL
Heb 6 1919
(Address)
Chelastres
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Feb. 4: 1919
17
I HEREBY CERTIFY, That I attended deceased from
January
, 1918 to Feb. 4th
19/9
Fab 3 rd
that I last saw her
...... alive on
1919
1,
and that death occurred, on the date stated above, at 10 a
The CAUSE OF DEATH* was as follows :
Hypertrophic Cirrhosis
Several .
.. (duration)
... yrs ....
mo6.
ds.
CONTRIBUTORY
(SECONDARY)
........
... (duration)
yrs ..
.mos ..
ds.
10 NAME OF FATHER Tudiew & Raymond
11 BIRTHPLACE OF FATHER (eity or town).
(State or country)
n.H.
12 MAIDEN NAME OF MOTHER abbie Stevens
13 BIRTHPLACE OF MOTHER (eity or town).
Bour
(State or country)
n.H.
14 Melon Walker
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
MARGIN RESERVED FOR BINDING
3 SEX Hemale 7 AGE 67 PARENTS Informant carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, of certificate. 15 Filed 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. Exaot statement of OCCUPATION is very important. See instructions on back (State or country)
State
Mais
176
·
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign hirth ?
years
LA
?E. : - ·
Statement of occa,
tion is very important, ou vnou vav !
various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of ..
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia,' "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"" "Debility" (“Con- genital," "Senile," "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- etc.), mus," "Old age," "Shock," "Uremia," "'Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. ª 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
ntributory." (Recommendations Jeath approved by Committee
clature or the American Medical Association.)
tor the Medical Examiners. - Under the provi-
chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
R. 15. 10-'18. 5,000.
Form R-302
The Commonwealth of Massachusetts
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
(ISSUED UNDER THE PROVISIONS OF REVISED LAWS, CHAPTER 24)
State Man
Registered No. 10
No. Russellbrand
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
John . Traversy
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No. Russell Road St.,. Ward.
(Usual place of abode) Length of residence in city or town where death occurred years 11 months
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
6 DATE OF BIRTH. PH Manche 11
"(Day)
(Year)
Years 10 Months 28 Days
If LESS than 1 day. ........ hrs. or ........ min.
17 I HEREBY CERTIFY, That I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows : NaturalCansa-meumables hypertrophied thymus.
(See reverse side for additional space)
18 Where was injury sustained if not at place of death?
(Signed)
Frank &Bulkiller
, M.D.
(Address)
Uyer Man
digi Examiner Der 10tt Hies Middleany 89
1919
Dale
(Month)
(Day)
( Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL St. Patrick's
DATE OF BURIAL
Feb. 8
-
(Montif) (Day) (Year)
ADDRESS
175 formar
21 Burial p it Edward J. Robban Official issued by position
Conn Clerk
22 Date of issue Del. 8, 1919
8-'18. 13,000.
1 PLACE OF DEATH County Middlesex City or Town 2 FULL NAME 3 SEX 4 COLOR OR RACE male Muito 5a If married, widowed, or divorced HUSBAND of (or) WIFE of (Month) 7 AGE If STILLBORN, enter that fact here 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 10 NAME OF 11 BIRTHPLACE OF (State or country) PARENTS 14 Informant (Address) should be carefully supplied. AGE should be stated EXACTLY. MEDICAL EXAMINERS should state CAUSE OF See reverse side for extracts from the laws relative to the return of certificates of death. DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information 9 BIRTHPLACE (City). (State or country) man.
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