USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 25
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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 discasc. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar mmcumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinitc); 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 disease; Chronic interstitial nephritis, etc. The contributory (sccondary 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" (inerely symptomatic), "Atrophy," ("Con- lapse," "Coma," "Convulsions,"' "Debili", " Col-
genital," "Senile," etc.), "Dropsy," "Exhaustion,"
"Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Urcmia," "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. 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." (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 ch- D .- of 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.
1
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.
15
Fil Nov 8, 2020.
Registrar of any of the Jorn where death occurred
Filed 7100.2% 1. 1920 Collard Rotting
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, a
1920
17
HEREBY CERTIFY, That I attended deceased from
30
20, to how 52
19
20
that I last saw MANalive on
.1.1
and that death occurred, on the date stated above, at .040
.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. (Sce reverse side for additional space.) yonephroies of Tet, Kidney
Several.
(duration) Ayrs
.ds.
CONTRIBUTO
Infection I Left Kidney
pepression of Uren(duration)
.yrs.
mos ..
ds.
18 Where was disease contracted
if not at place of death ?
afittome
no.
Did an operation precede death ?. Date of
Was there an autopsy ?.
year
What test confirmed diagnosis ?.
Clinical autore su
Jandin
get other deter
page
., 14.D.
(Signed)
$ 6. 192 (Address) Lowell
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Forefathers', Chelmsford.
DATE OF BURIAL nov. 8 1920
20 UNDERTAKER
Wms. H. Saunders Kowell
ADDRESS
MWEMAINLY MOYUNYAS SALYLS QSLINI daStAad
MARGIN RESERVED FOR BINDING
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
Lowel. 76
(City or town)
Registered No. 1520
(Place of death)
Registered No.
6.5
(Place of residence)
St ... 1 Ward
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
Walter, B. Emerson
(If in the Army or Navy of the United States, give rank, organization, etc.)
City or Town
helmaford No.
no. Road
St.
days
How long in U. S., if of foreign birth?
years
mootbs
days
PERSONAL AND STATISTICAL PARTICULARS
1 PLACE OF DEATH
City or Town
howwell
2 FULL NAME
(a) Residence.
State ....
mars
(Usual place of abode)
Length of residence in city or town where death occurred
years
3 SEX
4 COLOR OR RACE
ms.
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Cora Byam
7 AGE
Years
If STILLBORN, enter that fact bere
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Härmer
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
Chelmsford
9 BIRTHPLACE (city or town).
10 NAME OF FATHER
Joseph
PARENTS
14
Informant.
(Address)
Thelmheard Many
so that it may be properly classified. Exact statoment of OCCUPATION is very important. See instructions on back
(State or country)
mas's.
I
Months :
18 Days
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
6 DATE OF BIRTH (month, day, and year) Sepet. 18,1866
If LESS than
I day, ........ brs.
or ....... min.
11 BIRTHPLACE OF FATHER (city or toto) helms ford (State or country) maps. 1
12 MAIDEN NAME OF MOTHERarahit Byam
13 BIRTHPLACE OF MOTHER (city or towo helmcchord (State or country) mark
months
County
Middlesex
State
mass
howwell Con il top
19 ..
19. 20.
(SECONDARY). (alindi ap)
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, c. 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 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- 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 disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (discase causing death), 29 ds .; Broncho- pneumonia (sccondary), 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 ascertaincd as the cause. 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; 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, 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 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.
FORM R-301
The Commmuralth of Massachusetts
77
STANDARD CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
rudellexe
State.
Registered No.
66.
City or Town
North Sekund
St., Ward
(If death øgeurred in a hospital oy institution, give its NAME instead of street and number)
2 FULL NAME
Sempe Ht Smith
(a) Residence.
( Usual place of abode)
Length of resideoce in city or town where death occorred
60.
years
mooths
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Make White
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Hannah 4.
6 DATE OF BIRTH
Au 30th 1834
( Month)
(Day)
(Year)
7 AGE
84
Years
6
Months
5
Days
If LESS than
If STILLBORN, enter that fact here
If STILLBORN, state period of oterogestation
.. mos.
1 day, ........ hrs. or ........ mio.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work.
painter
(b) Generai nature of industry, bosiness, or establishment in which employed (or employer)
... (duration)
.. yrs ................. mos ..
ds.
CONTRIBUTORY.
antonio -velerozeo .
(SECONDARY)
(duration)
.yrs ...
mos. ds.
13 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 ? Fred E Jammen
(Signed)
, M.D.
(Address)
March Cheliefert
Date.
november 5
1920
( Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION. OR REMOVAL
DATE OF BURIAL
(Cemetery) (City or town)
20 UNDERTAKER
^ ADDRESS
21 I HEREBY CERTIFY that a satisfactory stan-
BEFORE the burial or transit permit was issued Edward & Robbins
Down Clock
position.
Date of issue of permit Nov. 8.1920
Permit
No
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
1920
novembro
20
to.
19
that I last saw h
alive on
19
and that death occurred, on the date stated above, at 8459
.m.
The CAUSE OF DEATH was as follows : Botas Pneumonia
(c) Name of employer
9 BIRTHPLACE (City) ( State or country)
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF
FATHER (City)
(State or country)
Dinetable
12 MAIDEN NAME
13 BIRTHPLACE OF MOTHER (City) (State or country)
Durtable
14 Bolletta
Informant ... (Address)
15 Nov.8, 1920 Edward J. Robbing (Month) (Day) (Year) REGISTRARY
1-6-'19. 150,000.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
november 5
1920
MARGIN RESERVED FOR BINDING
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
North Chebuford Ward.
(Ifin the Army or Navy of the United States, give rank, organization, ete.)
(If non-resident give city or town and State)
(Day)
6
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 he 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, c. 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 he used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Groccry; (a) Foreman, (b) Automobile factory. The material worked on may form part of tho 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 dutics of the house- hold only (not paid Housekeepers who receive a definite salary), may he 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 hcginning 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 disease. 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 need not be stated unless important. Example: Mcaslcs (disease causing death), 29 ds .; Bronchopneumonia (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions," "Debility" ("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 hy Com- miittee 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 1
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 helief the name of the deceased, his supposed age, the disease of which he died [defined so that it can he 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. 822.
No undertaker or other person shall bury a human body . . . until he has received a permit from the hoard 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 he accompanied hy a satisfactory certificate of the at- tending physician, if any, as required hy 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 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, Sec. $8.
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 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 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 disahled 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 hy the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following ahortion, hut 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 Commomuralth of Massachusetts
78
STANDARD CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
Registered No.
67
St ... Ward
(If death occurred iu a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Ann Maria Batohelder
(If in the Army or Navy of the United States, give rank, organization, ete. )
(a) Residence.
No.
Westford ..... Rd.
St.,
.Ward.
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
16 DATE OF DEATH
(Month)
nor.
6
1920
.....
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
that I last saw her alive on
nor 6
19 20
and that death occurred, on the date stated above, at
The CAUSE OF DEATH was as ,follows :
(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 ?
no.
Date of.
Was there an autopsy ?
20.
What test confirmed diagnosis ?..
(Signed)
Anton . Scoloria
, M.D.
(Address)
Chilisford, mass
Date
nor.
8
1920.
(Month )
( Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Riverside ,
(Cemetery)
NO .... Chelmsford
(City or town)
DATE OF BURIAL
Nov.9
20 UNDERTAKER ADDRESS Walter Perham, Chelmsford, Mass
21 I HEREBY CERTIFY that a satisfactory stan-
BEFORE the burial or transit permit was issned : Edward & Rolfing
Official Jorn Click
position
Date of
issue
of permite
Zurv. 9,920
Permit
1-6-'19. 150,000.
1 PLACE OF DEATH
County ..
Middlesex
City or Town
Chelmsford
( Usual place of abode)
3 SEX
Female
4 COLOR OR RACE
White
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Orrin S,
(Month)
7 AGE 8y
Years
U
Montlis
12
Days
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation
mos.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Housewife
(b) General nature ofindustry,
business, or establishment in
which employed ( or employer).
(c) Name of employer
(State or country)
10 NAME OF
FATHER
Charles Swett
11 BIRTHPLACE OF
(State or country)
12 MAIDEN NAME
OF MOTHER
ANna Babcock
PARENTS
(State or country)
14
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
FATHER (City).
Bedford ..... N.H.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widow
Batchelder
19
., to.
nor. 6
19
20
6 DATE OF BIRTH
Oct.
25
18.31
(Day)
(Ycar)
If LESS than
I day ......... brs.
or ....... min.
9 BIRTHPLACE (City)
Chelmsford, ..... Mass.
13 BIRTHPLACE OF
MOTHER (City)
Northboro , ..... Mass.
Informant
Mrs. E. C. Bartlett
(Address )
Chelmsford, Mass.
15
100. 9. 1920 Edward J. Robbins.
(Month) (Day) (Year)
REGISTRAR
State ...... Masg.
No ...... Westford Rd.
(If non-resident give eity or town and State)
PERSONAL AND STATISTICAL PARTICULARS
MARGIN RESERVED FOR BINDING
No.
m.
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 hcalthfulness of various pursuits can be known. The question applies to each and every person, irrespective of agc. 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, 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 necded. 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 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 heen changed or given up on account of the DISEASE CAUSING NEATH, state occupation at beginning of illness. If retired from husincss, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
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