USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 11
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
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 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60
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 BPACE FOR FURTHER STATEMENTS BY .
PHYSICIAN.
R 303. 6-'18. 50,000.
FORM R-301
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
39 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS 287673
1 PLACE OF DEATH
County.
City or Town ..
No.
State
actor
St.
.Ward
(If death occurred in a Hospital or institution, give its NAME instead of street and number)
Victor. Partner
(If in the Army or Navy of the United States, give rank, organization, etc. )
(a) Residence.
No.
SLulukard
St.,
.. Ward.
( Usual place of abode)
Length of residence in city or town where death occurred 35
years
months
days.
llow long in U. S., if of foreign birtb ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
W.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word) -
Zaned
5a If married, widowed or divorced
HUSBAND of
(or) WIFE of
Elizabetha /v. Partelara
6 DATE OF BIRTH
Geo 18 1878
( Month)
(Day)
( Year)
7 AGE
42
Years
2
Months
Days
If STILLBORN, enter that fact bere
If STILLBORN, state period of uterogestation
. mos.
If LESS than
I day, ........ brs.
or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or Tartar
particular kind of work (b) General nature of industry, bosiness, or establishment in which employed ( or employer)
(c) Name of employer
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 ?
no.
What test confirmed diagnosis ?.. (Signed). Nului 4, Scoloria
M.D.
( Address ).
13 BIRTHPLACE OF MOTHER (City) (State or country)
Towello
mass
Date
may 18 0 ideale
(Month) /
(Day)
(Year)
14 Elizabeth N. Parktwar
Informant.
(Address)
Chalinford mars
19 PLACE OE BURIAL, CREMATION, OR REMOVAL
Tarefathere Chelmsford.
(Cemetery)
(Citý/or town)
DATE OF BURIAL may 21-192.
15 May 19, 1920 Edward J. Rotting
REGISTRAR
20 UNDERTAKER
W.Huben Blakez.
ADDRESS Lowell
Permit
21 1 HEREBY CERTIFY that a satisfactory stan-
BEFORE the burial or transit permit was issued. Edward J. Robbing
Official position
Town Clerk
Date of issue of permit May 19, 1920 No. .......
20
that I last saw h MMM alive on
may/18
19 20
and that death occurred, on the date stated above, at.
6.30 P.
m.
The CAUSE OF DEATH was, as follows :
(Primary)
( duration)
.. yrs ...
.mos ..
6
ds.
Lowell
9 BIRTHPLACE (City)
(State or country)
mais
10 NAME OF
FATHER
DE LePlayParkturns
11 BIRTHPLACE OF
FATHER (City ).
Thehanford
(State or country)
mass
12 MAIDEN NAME
OF MOTHER
Adella Osgood
PARENTS
1-6-'19. 150,000.
MARGIN RESERVED FOR BINDING
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH 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. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
mase
Registered No.
2 FULL NAME
(If non-resident give city or town and State)
16 DATE OF DEATH
may 18-1920
(Month
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
20 to
may 18
19
May 14
19
........
Filed (Month) Day) (Year)
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupation 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, Locomotive engineer, Civilengineer, 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 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 house- hold 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 indicated 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 diseasc. Examples: Cere- brospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, men- inges, peritoneum, 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 necd not be stated unless important. Example: Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senilc," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 322.
No undertaker or other person shall bury a human body . .. until he has received a permit from the board of health or its agent, . . . or . . . from the clerk of the city or town in which the person died; . . . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written statement con- taining the facts required by law to be returned and recorded, which ... shall be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in lieu thereof a certifi- cate as hercinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. . . . The person to whom the per- mit is so given and the physician who certifies to the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Scc. 88.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise a description of such person as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are supposed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
FORM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
,
State, Mass
Registered No.
29
City or Town
dichins And.
No
Entram r. E. Chelmsford St.
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(a) Residence.
No ...
Infran St & Lichns ns.
Ward.
(If non-resident give city or town and State)
Leogth of resideoce in city or towo where death occorred
years
months
4
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
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)
(Year)
Years 20
Months
Days
If LESS than 1 day, ........ his. cr ........ mio.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED (a) Trade, professioo, or particular kind of work ..
9 BIRTHPLACE (City)
(State or country)
brass-
11 BIRTHPLACE OF FATHER (City). (State or country)
Incland.
12 MAIDEN NAME
OF MOTHER
Bridget Olaf
13 BIRTHPLACE OF MOTHER ( City) ... (State or country) Incland.
15 Filed Fr June 1, 1920 Edward J. Robbins (Month) (Day) (Year) REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stao- dard certificate of death was filed with me BEFORE the borial or transit permit was issued
60 Ochward. Roffing
Official position
Town Clark
Date of issue Of permit Samme 1 19 20 No
Permit
11-13-'19. 50,000.
3 SEX 7 AGE 10 NAME OF FATHER PARENTS 14 Informant ...... (Address) 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. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH (b) Name of employer
The Commonwealth of Massachusetts
40
(City or Town)
County
Igualesex
Mary Classes Meagher.
If in the Army or Navy of the United States, give rank, organization, etc.)
1920
16 DATE OF DEATH
(Month)
17
HEREBY CERTIFY, That I attended deceased from
Ich 2301
19.
May 20
20.
to
19
20
that I last saw h
alive on
may 28
19.
20
and that death occurred, on the date stated above, at
2PM m. The CAUSE OF DEATH was as follows :
. Pulmonary tuberculosis
2 ...
(duration)
... yrs ..
23
mos.
ds.
CONTRIBUTORY.
Influenza
(SECONDARY)
(duration)
yrs ..
mosc
21
ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death ?
no
Date of
Was there an autopsy ?
Gammation of partir
What test confirmed diagnosis ?
(Signed)
M.D.
(Address)
468 gradgest
Date. Jeune Del 1920
Hacer (Month)
(Day) 1920 ( Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL It Jatricks
DATE OF BURIAL
Truelle
(Cemetery)
(City or town)
20 UNDERTAKER
ADDRESS Sowell
7
MEDICAL CERTIFICATE OF DEATH
30
(Day)
(Year)
MARGIN RESERVED FOR BINDING
( Usual place of abode)
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupation 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 werd or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, 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 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 house- hold only (not paid Housekeepers who reccive 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 indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATII (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cere- brospinal fever (the only definite synonym is "Epidemic cercbrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (ncver report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, men- inges, peritoneum, 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 .; Bronchopneumonia (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," "Ancmia" (merely-symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Dcbility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis, " etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to tho best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contractcd, the duration of his last illness, when last secn alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1. as amended by Acts of 1910, Chap. 322.
No undertaker or other person shall bury a human body . . . until he ..... has received a permit from the board-of health or its agent, .. ... or . .. from the clerk of the city or town in which the person dicd; . .. no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written statement con- taining the facts required by law to be returned and recorded, which ... shall be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in lieu thereof a certifi- cate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physician employed . by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. . .. The person to whom the per- mit is so given and the physician who certifies to the cause of death shall thereafterfurnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise a description of such person as full as may be, with the cause and manner of his death, and shall make examinatien upon the view of the dead bodies of only such persons as are supposed to have come to their death by violencc. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from heme when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include net only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
FORM R-301
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
41
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH Middleace County.
State
Dass ..
Registered No.
30
St ..
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Mary Ryan
Columbus Que
St.,
Ward.
(If non-For
. give city or town and State)
Length of residence ia city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth?' 136 -44%.
months
days
1920
16 DATE OF DEATH.
(Maith)
(Day)
(Year)
17 HEREBY CERTIFY, That I attended deceased from July 31 19
.. .
that I last saw h .........
alive on
19
Que 31
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH was as follows : 5
-
(duration)
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 ?.
Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
M.D.
(Address
Date
(Month)
(Day)
( Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL St Patricks Lourel Julie 3 19 20 Cemetery) (City or town)
20 UNDERTAKER
ADDRESS NouvelMais
Permit
21 I HEREBY CERTIFY that a satisfactory stan-
1-6-'19. 150,000.
2 FULL NAME (a) Residence. No. ( Usual place of abode) 3 SEX 4 COLOR OR RACE faciale 6 DATE OF BIRTH ( Montlı) 7 AGE 64 Years + Months 8 OCCUPATION OF DECEASED (a) Trade. profession, or particular kind of work (h) General nature of industry, business, or establishment in which employed (er employer ). (c) Name of employer 9 BIRTHPLACE (City) (State or country) 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (City) (State or country) 12 MAIDEN NAME OF MOTHER 13 BIRTHPLACE OF PARENTS MOTHER (City) (State or country) (Address) should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH 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. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See If STILLBORN, enter that fact here If STILLBORN, state period of nterogestation ....... mes.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED. WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, er divorced
HUSBAND of
(or) WIFE of
Patrick Ryan
(Day)
(Year)
Days
If LESS than
1 day, ........ hrs.
or ........ min.
at Home
Fuland
Unknown
Juland
Mary Haley
Duland
14 Patrick Byay
Informant .... Soleillas Erte, En Cheelin
15 Some 2 1920 Edward J. Bobbing
Filed .. (Month) (Day) (Year)
REGISTRAR
Official Torm Clock position
Date of issue of permit.
BEFORE the burial or transit permit was issued .
MEDICAL CERTIFICATE OF DEATH
(If in the Army or Navy of the United States, give rank, organization, etc.)
City or Tow
8. Clichesford
No.
Columbus ave
MARGIN RESERVED FOR'BINDING
Boyle
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association!
-
Statement of occupation. - Precise statement of occupation 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 Plontcr, Physicion, Compositor, Architect, Locomotive engineer, Civilengineer, Stationary firemon, ctc. Butin 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 ouly when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Solesman, (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 Doy laborer, Farm laborer, Laborer - Cool mine, etc. Women at home, who are engaged in the duties of the house- hold only (not paid Housekeepers who receive a definite salary), may be entercd 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, Housemoid, 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: Former (retired, 6 yrs.). For persons who have no occupation whatever, write None.
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