USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 4
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, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 10-'18. 5,000.
.
----
-
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
20 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
Middlesee
State Mass
City or Town ...
No Chelinaford
No.
Highland ave
St ......... Ward
If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Quew FM@ Grath
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
(Usual place of abode)
Highland are No Chelist for Vard.
Length of residence in city or town where death occurred
47
years
months
days.
How long in U. S., if of foreign hirth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
Write
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)
7 AGE 47 Years
Months
Days
If LESS than
1 day, ........ brs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
Machinist
particular kind of work
(h) General nature ofindustry,
business, or establishment in
which employed (or employer)
Moore 's Mill
(c) Name of employer
9 BIRTHPLACE (City)
No Chelmsford
(State or country)
man
10 NAME OF
FATHER
Owen Mcgrath
11 BIRTHPLACE OF
FATHER (City ).
Freland
12 MAIDEN NAME
OF MOTHER
alice M& Sale
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Iseland
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
17
I HEREBY CERTIFY, That I attended deceased from
Jan 252
1970
to.
that I last saw
alive on
, 19.
20
and that death occurred, on the date stated above, at ......... m.
The CAUSE OF DEATH was as follows :
Cerebral Hemonds
( duration)
.yrs.
mos. 12 ds.
CONTRIBUTORY
(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 ).
Date
Ich
11
1920
( Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Ihatriche (Cemetery) (City or town)
DATE OF BURIAL
Lowell Tel: 12-1920
15 Fiel 11, 1920 Edward ). Robbing
Filed (Month) (Day) (Year)
REGISTRAR
20 UNDERTAKER
Mances , O Donnellnous 024 Market,
ADDRESS
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. Roffing
Official Conn Check position
Date of issue of permit Fibres 920%
Permit
1-6-'19. 150,000.
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
FORM R-301
MARGIN RESERVED FOR BINDING
PARENTS
14 Mary E. Mª Grath Sister
Informant
(Address)
To thelong ford
Registered No. 9
( If non-resident give city or town and State)
9
1920
(Day)
(Year)
....
Date of
(State or country)
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation
mes.
1873
XTRACTS
OF THE
MASSACHUSETTS
GOVERNING THE
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, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is neecssary 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) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specifieation, as Day laborer, Farm laborcr, 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- eifieally the occupations of persons engaged in domestie 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 heginning of illness. If retired from business, that fact may be indicated thus: Farmer (rctircd, 6 yrs.). For persons who have no occupation whatever, write None.
Holan
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respcet to time and eausation), using always the same accepted term for the same disease. Examples: Cere- brospinal fever (the only definite synonym is "Epidemie 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, ete., 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, ete. The contributory (secondary or inter- current) affection need not he stated unless important. Example: Mcasles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Ancmia" (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 ean be ascertained as the cause. Always qualify all diseases resulting from childhirth or miscarriage, as "LUER- PERAL septicemia," "PUERPERAL peritonitis,"' etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved hy 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, childhirth, 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, the duration of his last illness, when last seen alive hy 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 beard of health or its agent, . . . or . .. from the clerk of the eity 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 thereafterfurnish for registration any other necessary information which ean he ohtained 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 elerk 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 eause 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. - Reviscd 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 ferm 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 traumatisni (including resulting septicemia), and by 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-301
MARGIN RESERVED FOR BINDING
(c) Name of employer PARENTS (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 (State or country)
The Commonwealth of Massachusetts
21
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
Middlesex
State
mass
Registered No.
10
St.
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Mary Ellen Slove
(a) Residence. No.
3 67 Hannover St-Manchester Midt.
(If non-resident give city or town and State)
Length of resideoce in city or town where death occurred
years
3
months
days.
How long in U. S., if of foreign birth ?
67
years
10 months
- days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female Write
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Franke E. Store
april
1852
(Day)
(Year)
7 AGE
6 7Years
Months
Days
If STILLBORN, eofer that fact bere
If STILLBORN, state period of uterogestation
mos.
If LESS than
1 day, ........ brs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(h) Geoeral nature ofindustry,
business, or establishmeot in
which employed (or employer ).
at home
9 BIRTHPLACE (City)
Dover
ma.
10 NAME OF
FATHER
Patricke Walker
11 BIRTHPLACE OF
FATHER (City)
Queland
(State or country)
12 MAIDEN NAME
OF MOTHER
Ellen Stanton
13 BIRTHPLACE OF
MOTHER (City)
Ireland
(State or country)
14 Mary E. Walker, nece
Informant.
Washington D.C.
15
Fill 13 1920 Schwand )Robbing
(Month) (Day) (Ycar)
REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Laurel Still
Saco ME
(Cemetery)
(City or town)
DATE OF BURIAL
Freb. 16
20 UNDERTAKER 2
James H. O Donnell Hons
ADDRESS
324 market
Permit
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me
MEDICAL CERTIFICATE OF DEATH
Fel
13
1920
16 DATE OF DEATH
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
nov. 28. 1919, to.
7 et 13
., 1920.
that I last saw h: 21
alive on
7 cb 13
, 19 20
and that death occurred, on the date stated above, at.
11 G, m.
The CAUSE OF DEATH was as follows :
Carcinoma of Seven
( duration)
1
.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 ?
WWW. Date of.
Was there an autopsy ?
no.
What test confirmed diagnosis ?
(Sigoed)
Le
Bential
(Address).
Date
Jeh
13
1920
( Month)
( Day)
(Year)
M.D.
Official position Com Click Date of issue of permit ... tel 13,19.20 No.
1-6-'19. 150,000.
STANDARD CERTIFICATE OF DEATH
City or Tow
to Chelmsford
No.
(If in the Army or Nayy of the United States, give rank, organization, etc.)
(Usual place of abode)
6 DATE OF BIRTH
( Month)
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Stoban
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 cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Former or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stationory fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (o) 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 Doy laborer, Farm laborer, Loborer - Goal 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 NEATH (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 definito 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); Meosles; Whooping cough; Chronic valvulor heart disease; Chronic interstitial nephritis, ctc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (discase causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapsc,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., wheu a definite disease can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," ctc.
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 deccased, 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, Chop. 29, Secs. 10 ond 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 dellvered 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.
Mcdical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deccascd 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 persens to whom they have given bedside eare during a last illness from discase unrelated to any ferm 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, tho sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
FORM R-301
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
1-6-'19. 150,000.
The Commmuralth of Massachusetts
STANDARD CERTIFICATE OF DEATH
OFFICE OF TIIE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH Middlezena
County.
State
Massachusetts
Registered No 11
St. Ward
(If death oceurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
luna.
Erena, Pickhul
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
Chelmsford
St.,
Ward.
(If non-resident give city or town and State)
Length of residence in city or town wbere death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Limala
4 COLOR OR RACE
Ahita
5 SINGLE, MARRIED, WIOOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
Juna-23-1917
(Month)
(Day)
( Year)
7 AGE
2
Years
Months 21 Days
If STILLBORN, enter that fact here
If STILLBORN, state period of nterogestation
mos.
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work. (b) Generai nature of industry, business, or establishment in wbich employed ( or employer ).
(c) Name of employer
9 BIRTHPLACE (City)
Lowell. Masz.
(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 ?
Regular Tes
(Signed)
., M.D.
(Address) ..
53 central At
Date
Fct-
15
1970
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Marthal
main
.
DATE OF BURIAL
200 /6
19.20
(Cemetery)
(City or town)
20 UNDERTAKER
David L Greig & Son.
ADDRESS
AVartead 1/2
1312
Permit
21 I HEREBY CERTIFY that a satisfactory stan-
BEFORE the burial or transit permit was issued Edwardi Robbins
Official
position
Vonn Club
Date of issne of permit Feb, 16, 1926
(Day)
(Year)
17 I HEREBY CERTIFY, That I attended deceased from Feb 7 1920, to Feb 13 , 19. 20
that I last saw han
alive on
13
19 20
and that death occurred, on the date stated above, at 1/4.
m.
If LESS than
The CAUSE OF DEATH was as follows :
1
Tubercular Menageles
(duration)
.yrs ..
.mos
.ds.
( State or country)
10 NAME OF
FATHER albert R Pickhuf.
11 BIRTHPLACE OF FATHER (City). (State or country)
12 MAIDEN NAME
OF MOTHER
Fania anderson
13 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Quincy Mark
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Month)
Feb
14
1920
MARGIN RESERVED FOR BINDING
PARENTS
14 Miss Edith M. anderson
Informant
(Address)
2. Chelmsford.
15
Feb. 16, 1920 Edward , Bottom
(Month) (Day) (Year)
REGISTRAR
22
City or Town
Chelmsford.
No.
( Usual place of abode)
months
days
CONTRIBUTORY
( SECONDARY)
En UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Associati.
Statement of occupation. - Precise statement of occupation is very important, so that tho 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 tho first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stationary fireman, etc. 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 he 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 laborcr, Laborer -- Coal mine, ctc. Women at home, who are engaged in the duties of the house- hold only (not paid Ilousekeepers 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, 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.
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