USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 36
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single
(Ifin the Army or Navy 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. - Precise statement of occupa- tion is very important, so that tlic 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- ilor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial einployinents, 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 forin 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 froin business, that fact may be indi- cated thus: Farmer (retircd, 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 witli respect to time and causation), using always the same accepted term for the sainc 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, etc., of ..
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; 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 &s .; 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," "Senilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," cte. Statc 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
niendations
on state, . vi deat & 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 discase, 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-302
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
( City or town)
Registered No ..
702
(Place of death) }
Registered No.
20-18
(Place of residence)
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME.
Henry W. Lathrop
City or Town
months
12
days
How long in U. S., if of foreign birth?
years
months
days
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Har . 26,
1927
17 I HEREBY CERTIFY, That I attended deceased from
Mar ..
14
19
to
21
Mar. 26,
21
19
im
Mer. 26,
21
that I last saw h
alive on
19
and that death occurred, on the date stated above, at
10:201
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.) Arteriosclerosis
.(duration)
+
yrs.
mos
ds.
CONTRIBUTORY
Cerebral Haemorrh me
(SECONDARY)
(duration)
yrs.
mos.
?
ds.
10 NAME OF FATHER
Edward La thro
11 BIRTHPLACE OF FATHER (city or town)
Not learned.
(State or country) Massachu etts.
12 MAIDEN NAME OF MOTHER Not learned.
What test confirmed diagnosis?
(Signed)
George A. Peirce.
. M.D.
. 19 21 (Address)
St to Infirmary. Te evry
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Pine Ridge
Com
Cholms-
Lord,
HasE.
DATE OF BURIAL Man. 28 1921
Filed Mar, 31
Kinhals, Butl. Registrar of city or town where death occurred 1921 Justice Li Marce Registrar of city or town where deceased resided
20 UNDERTAKER
Elter Derham
ADDRESS
Chelmsford,
1 PLACE OF DEATH
County
Middlesex
City or Town
Tewksbury
(a) Residence.
State
(Usual place of abode)
Length of residence io city or town where death occorred
years
3 SEX
Ma le
4 COLOR OR RACE
Whi to
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Not Learned.
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
Months
65
2
If STILLBORN, enter that fact bere
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
Teamster
particular kind of work
(h) General natore of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town)
Avon
PARENTS
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
14
Informant
Infirmary,
15
3
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
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. Exact statoment of OCCUPATION is very important. See instructions on back
(State or country)
Massachusetts.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widower
Jan. 16, 1856
Days
10
If LESS than
I day, ........ hrs.
or ....... min.
MARGIN RESERVED FOR BINDING
State
Massachusetts.
No ..
Stile Infirmary
(If in the Army or Navy of the United States, give rank, organization, etc.)
No.
Che Imsford. Lass.
St.
PERSONAL AND STATISTICAL PARTICULARS
3/06
NOT LOGANDO.
Not learned
Hospital Bogo rot. ..
18 Where was disease contracted
if not at place of death ?
Chelmsford
Did an operation precede death ?.
IO
Date of
Was there an autopsy ?.
105
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 inany 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," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at hoinc, who are engaged in the duties of the houschold 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 spc- 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 faet 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 tiine and causation), using always the same accepted terin 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- toneum, etc., Carcinoma, Sarcoma, etc., of_
(naine origin; "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); 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 (discase causing death), 29 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- tomns or terminal conditions, such as "Asthenia," "Ancmia" (inercly symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"""Debility" ("Con- genital," "Scnile," 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 discases resulting from child- birthı 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 carbolie 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." (1' wiions on statement of cause of death appro; unmittee
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 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.
FORM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
106 Chelmsford
1 PLACE OF DEATH
County.
City or Town
Chelmsford
No.
St .. .. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Cora R. Cudworth
(If in the Army or Navy of the United States, give-rank, organization, etc.)
(a) Residence.
No.
North Road
St.,
.....
.Ward.
(If non-resident give city or town and Statc)
Length of residence in city or town where death occurred 20
years
months
days.
How long in U. S., if of foreign birth ?
years
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 divorced
HUSBAND of
(or) WIFE of
Chao. M. Cudworth
6 DATE OF BIRTH
-
30 1861
( Month)
(Day)
( Year)
7 AGE
Years
Months
2
Days
5
if LESS than 1 day, ........ hrs. or ........ min.
If STILLBORN, enter that fact bere
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
at home
9 BIRTHPLACE (City)
Marlboro n.H.
(State or country)
Imderick Rouillard
11 BIRTHPLACE OF
FATHER (City)
action
(State or country)
mass
12 MAIDEN NAME
OF MOTHER
not known
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
(Address).
Date
auf 4
1921.
( Month)
(Day)
(Year)
Informant
Chao M Cudevona
(Address)
Chelmsford
15 Filed arr. 5, 1921
Justice & resort
(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 Justice L. More
Official -position
From Heck
Date of issne of permit apr. 51921 No.
Permit
......
...... ...
17
I HEREBY CERTIFY, That I attended deceased from
Jack 14
1921
app 4
19
21
that I last saw her
alive on
Capul 4
19
21
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH was as follows :
not Known,
(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.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Woodlawn
action Man
DATE OF BURIAL april 6 1921
(Cemetery)
(City or town)
20 UNDERTAKER Walter Perham
ADDRESS
Chelmsford
8-'20. 35,000.
3 SEX Hemmales 60 10 NAME OF FATHER PARENTS 14 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
MARGIN RESERVED FOR BINDING
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
(Year)
4.
1927
( Usual place of abode)
State
mars
(City or Town) ナ22
Registered No ..
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, 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 "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 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: Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "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 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,
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, tie 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 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. 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 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 clectrical 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 persone found dead,
:
FORM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
107 Chelmsford
1 PLACE OF DEATH
County
maex
City or Town
Chelmsford
No ..
St .. .. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Sarah Ellen Stearns
(If in the Army or Navy of the United States, give rank, organization, ete.)
(a) Residence. No.
Dalton Road
St.,
.............. Ward.
(If non-resident give eity or town and State)
Leogth 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
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
..
Nulow
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
James H Stearna
6 DATE OF BIRTH.
7March
( Month)
29 1800
(Day)
(Year)
7 AGE
Years
Months
G
Days
8
if LESS than 1 day, ........ hıs. or ........ min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
at home
9 BIRTHPLACE (City)
Maitland
(State or country)
nova Scotia
10 NAME OF
Cochrane
FATHER
11 BIRTHPLACE OF
FATHER (City)
(State or country)
nova Scotia
12 MAIDEN NAME
OF MOTHER
not known
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
nova Scotia
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 ?
(Sigoed)
Daniel J. Ellison
M.D. (Address) 8 mechinach Torrell
Date.
afmil
7
1921
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Edson
Lowell
(Cemetery)
(City or town)
DATE OF BURIAL
april 8 1921
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
21 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued Suite L. Moore
Official position.
Store Clerk
Date of issue of permit. apa, 8, 1921 No .
Permit
.......
3 SEX Finale 71 PARENTS 14 Filed 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 (h) Name of employer
MARGIN RESERVED FOR BINDING
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