USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 16
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(SECONDARY)
(duration)
.. yrs ...
mos.
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?.
no
Was there an autopsy ?
no
What test confirmed diagnosis ?
(Signed)
/M.D.
(Address);
250 Westford 2!
Date July
29 1920
(Month)
( Day)'
(Year)
14 Charles P. Wright
Informant (Address)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Gelsen Cincuenta (Cemetery)
(City or town)
19
ADDRESS
15 July 31 1920 Edward , Robbins
Filed ... (Month) (Day) (Year)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued Edward J. Robbing.
Official position.
Tough Click
22 Date of issue of burial or transit permit.
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
PARENTS
11 BIRTHPLACE OF FATHER (City ). n. Bellina (State or country)
12 MAIDEN NAME OF MOTHER Maud. Brown
13 BIRTHPLACE OF MOTHER (City) (State or country) auce!
Sowell, Mass.
MEDICAL CERTIFICATE OF DEATH
July
29
1920
(Day)
(Year)
17 HEREBY CERTIFY, rom
19
July 29,19 20
that I last saw h
walive on
and that death occurred, on the date stated above, at.
The CAUSE OF DEATH was as follows : .
acctubacio
(duration)
.yrs ..
mos.
dst
9 BIRTHPLACE (City) (State or country)
Part Chelive
10 NAME OF
FATHER
Charles P. Wright
Date of
DATE OF BURIAL
20 UNDERTAKER
Wim @ Mack.
10-'18. 100,000.
(a) Residence.
No.
( Usual place of abode)
Length of residence in city or towo where death occorred
years
months
days.
How long io U. S., if of foreign birtb ?
years
16 DATE OF DEATH
(month )
29,192 4.30 P.m. .. m.
MARGIN RESERVED FOR BINDING
STANDARD CERTIFICATE OF DEATH Mars.
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Associatioo]
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 he sufficient, e. g., Farmer or Planter, Physician, Compositor, 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 material worked on may form part of the second statement. Never return "Lahorer," "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 he taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If tho occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from husiness, 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 discase. Examples: Cere- brospinal fever (the only definite synonym is "Epidemic ccrehrospinal 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 need 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,""Dehility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can he ascertained as the cause. Always qualify all diseases resulting from childhirth 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 licu 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 thereafter furnish for registration any other neccssary information which can he 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 he, with the cause and manner of his death, and shall make examination upon the vicw of the dead hodies of only such persons as are supposed to have come to their death hy violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the ohservance 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 dicd 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 hy the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following ahortion, 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-302
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT OU
well
(City or town)
1 PLACE OF DEATH
County
middlesex
State
mars,
Registered No.
119
(Place of residence)
St., ......... Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
marie Louise pelagic
mass
(a) Residence.
State
City or Town helyeken No.
St.
(Usual place of abode)
Length of residence in city or towy where death occurred
years
mouths
6
days
How long in Ul/S.,. 1.
27
years 8
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year july 30 19 20
HEREBY CERTIFY, Thay I attended deceased from July 24 1926, mely 30 2.0
130
20.
that I last saw her, live on
19
and that death occurred, on the date stated above, a? .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. ) Puerperal clampsia
(duration).
.. yro.
mos.
6
.ds.
CONTRIBUTORY
(SECONDARY)
(duration)
yrs
mos.
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.
7-31. 19 2 ( Adress) Chelmsford
. 19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL St. Josephchelmsford ling. 2 1920
20 UNDERTAKER a archambault Lowell
ADDRESS
Filed ang. 19 19 20 Edward & Rotting
Registrar of city or town where deceased resided
MARGIN RESERVED FOR BINDING
Years 27 (b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, If STILLBORN, enter that fact here
Lowell
9 BIRTHPLACE (city or tom)or
masa.
10 NAME THEFrancois / Traversy
11 BIRTHPLACE OF FATHER (city or town) (State or country) canada
12 MAIDEN NAME OF MOT Cannot be learned
13 BIRTHPLACE OF MOTHER (city or town) (State or country) Canada
Informant (Address) Chelmsford las
Registrar of city. or town where death occurred
Registered No.
(Place of death)
City or Town ...
howell
4 COLOR OR RACE
WS.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
William
6 DATE OF BIRTH (month, day, and yearto - 19,1892
Months
Days
8
If LESS than
1 day, ....
... brs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
tousepeyser
3 SEX 7 AGE PARENTS 14 15 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 statoment of OCCUPATION is very important. See instructions on back (State or country)
53
........
ds.
MAfuin the Army or Mavy of the United States, give rank, organization, etc.)
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Prceise 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 term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architeet, Locomotive engincer, Civil engineer, Stationary fireman, ete. 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," 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 domestie service for wages, as Servant, Cook, Housemaid, cte. 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 "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- toncum, etc., Carcinoma, Sarcoma, ete., 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 .; Broneho- pneumonia (secondary), 10 ds. Never report mere syinp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" (“Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," s." "Old age," "Shock,"Uremia," "Weakness," ete., when a definite disease can be aseertained as the cause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. 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, cte.
2. Deaths supposedly eaused 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, ete.
4. Deaths under circumstances unknown, as A person found dead, cte.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
:
R 303. 6-'18. 50,000.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
3 SEX
m.
7 AGE
PARENTS
so that it may be properly classified. Exact statoment of OCCUPATION is very important. See instructions on back
(State or country)
4 COLOR OR RACE
www.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (workte the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and reat) w9 , 1920
Years
Months
Days
If LESS than I day ..... ... brs. or ....... min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED (a) Trade, profession, or particslar kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city of town) howell
mais.
10 NAME OF FATHER Leroy
11 BIRTHPLACE OF FATHER (city of town) helmaford (State or country) macht
12 MAIDEN NAME OF MOT Kelly axworthy
13 BIRTHPLACE OF MOTHER (city of town (State or country)
ELland
14 Father Informant (Address) Chelmsford mars
15
Filelang 3, 19h 0 stephen Flynn (P. Filed any 20, 1920 Oderard &. Rollos
Registrar of city or towy where death occurred
Registrar of city or town where deceased resided
16 DATE OF DEATH (month, day, and yet lequel) 1920.
17 I HEREBY CERTIFY, That I attended deceased from augustil 9 2 W) to Wing, 1 1920.
1920.
that I last saw has.MA. alive on
and that death occurred, on the date stated above, at 11 yo ......... 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.) Premature Birth
.(duration).
.............. ds.
CONTRIBUTORY
(SECONDARY)
(duration)
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)
2
Rug3, 1920 ( Address) grhowell M.D.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL Riverside Chelmsford ung, 3 1920
20 UNDERTAKER
Yes, W. Healey
54
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
ell
(City or town) 1115"
1 PLACE OF DEATH
County ......
Middlesex
State.
maso
Registered No.
118
City or Town
Lowell
Lowell Gew Hoek Sty.
.Ward
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
mass.
City of Town les
(If in the Anny or Nafy of the United States, give rank, organization, etc.) helmslord No. St.
(a) Residence. State
(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
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
Registered No ...
(Place of death)
(Placp of residence)
haben
MARGIN RESERVED FOR BINDING
ADDRESS
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - 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 term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architcet, 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) 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," a," unquali- ficd, 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 necd not be stated unless important. Example: Measles (discase 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- 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- 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 Medicai 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, etc.
2. : Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized discasc, as A death upon the street, or onc 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.
FORM R-301
MARGIN RESERVED FOR BINDING
11-13-'19. 50,000.
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
55
Chemsford. (City of Town)
Registered No.
St. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Privata
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.,
.....
.. Ward.
Charlesto
(If non-resident give city or town and State)
Length of residence in city or town where death occurred
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