USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 41
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
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
" ØNIGY-NA -----------
FORM
FORM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Middle
State Mass.
Registered No.
35 34
St .............
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
actimus W. nelson.
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No ...
1543 Borham
St.,
Ward.
(If non-resident give city or town and State)
(Usual place of abodc)
Length of resideoce in city or town where death occorred
years
months
days.
How long in U. S., if of foreign birth ?
years
months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH May
(Month)
(Day)
1921. (Year)
17
I HEREBY CERTIFY, That I attended deceased from
LAPS 20th
1921, to.
hay 17th
19.21.,
that I last saw h
alive on
19
......
and that death occurred, on the date stated above, at
2
a m.
The CAUSE OF DEATH was as follows : Internal Hemoschange
(duration)
..... yrs ..
......
.mos.
.. ds.
CONTRIBUTORY
(SECONDARY)
(duration)
.yrs .............
mos ..
.2.7 ..... ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death ?
200
Date of.
Was there an autopsy ?
no
What test confirmed diagnosis ?
(Signed)
Wesley Queze
M.D.
( Address)
83 Versiondi
18 1921
Date
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Znull
(Cemetery)
(City or town)
DATE OF BURIAL May 19, 1921,
ADDRESS
20 UNDERTAKER W. H. Sauriduce
217 APPLETON STI
Permit
6-'20. 20,000.
21 I HEREBY CERTIFY that a satisfactory stanf dard Certificate of death was filed with me BEFORE the burial or transit permit was issued
geri Leisti L. Heran Official Grow Check
Date of
Issoe May 18, 192 % of permit ...
....
4 COLOR OR RACE
White.
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 November ( Month)
3 1896 (Year)
(Day)
Years
Months
Days
If LESS than 1 day, ........ brs. ..... mîn.
li STILLBORN, enter that fact bere
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
at home.
9 BIRTHPLACE (City)
Lowell
(State or country)
Mass.
10 NAME OF
FATHER
Élkanak Helen
11 BIRTHPLACE OF
FATHER (City)
(State or country) Novia destra.
12 MAIDEN NAME
OF MOTHER
Clementina Glover.
13 BIRTHPLACE OF MOTHER (City) (State or () Prince Edward Island
14 Elkarch Helena
(Address) East 6 helge ford
15 May 18 1921 Justine L. Marc
Filed: (Month) (Day) (Year)
REGISTRAR
MARGIN RESERVED FOR BINDING
24
6
14
119 Travaille 35 (City or Town)
City or Town ..
East Chelongford
No. 1543 Gorham
3 SEX Male. , 7 AGE PARENTS Informant .. 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
'ilcesation , Intestines
17,
FORM
40118W10141 10 W91: A03 0003 LNS
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 lino will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive enginecr, Civilengineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the house- hold only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employcd, 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 acceunt 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 discase. 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 indefinitc); 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" (mercly symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Urcmia,""Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases 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.
ACIUNVI VI
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 322.
No undertaker or other person shall bury a human body . . . until he has received a permit from the board of health or its agent, . . . or . . . from the clerk of the city or town in which the person died; . . . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written statement con- taining the facts required by law to be returned and recorded, which ... shall be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in lieu thereof a certifi- cate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. . . . The person to whom the per- mit is so given and the physician who certifies to the cause of death shall thereafterfurnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deccased 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 caro during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
INANYWHOA V SI SIHL - YNI YOVIR ONIGVINH HIM ----------- - - --
ĐNIANIE
FORM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Middlesex
City or Town
Chlemsford
State Mass
Registered No.
36 (City or Town)
3635
No. Boston Road Chlemsford Centre St.
Ward (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Anna ...
silva
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
N.Boston Road Chiensford (st.,
Ward.
(If non-resident give city or town and 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 foreigo birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
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 May
( Month)
10 (Day)
1921 ( Year)
Years
Months
Days
8
If LESS than
1 day, ........ hrs.
or ....... min.
If STILLBORN, eoter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
None
11
CONTRIBUTORY.
(SECONDARY)
(duration) ....... mos .. ...... ds. .. yrs,
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 ?. Antun G. Scolona. M.D.
(Signed)
(Address).
Chelo ford, mado.
may 19 0 1921.
Date
( Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
St. Patrick's Lowell
(Cemetery)
(City or town)
May 19/21
ADDRESS
20 UNDERTAKER J.L. McDonou~}
176 Gorham
LORGII
Date of issue
of permit May 1 9 19 2nd
-
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
may 18
(Day)
1921.
(Year)
17 I HEREBY CERTIFY, That I attended deceased from may12 1921, co. May 18 19
21
that I last saw h .A. alive on
may 14
1921
and that death occurred, on the date stated above, at.
m.
The GAUSE OF DEATH was as follows : Premature Birch
(duration)
.. yrs .............
mos
6
ds.
9 BIRTHPLACE (City)
(State or country)
Chlemsford Centre
10 NAME OF
FATHER
Joseph Silva
11 BIRTHPLACE OF FATHER (City) (State or country) Maderia
12 MAIDEN NAME
OF MOTHER
Maria Gracia
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Maderia
Informant ... Joseph Silva
(Address)
Boston Road Chlemsford Ct
15 May 19 1921 midin h. more (Month) (Day) (Year) REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stay- dard certificate of death was filed with me BEFORE the burial or transit permit was issued i Justin R. Moore Officia
. position
iran check
6-'20. 20,000.
3 SEX Female 7 AGE PARENTS 14 should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH (h) Name of employer
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
1 20
S
Statement of occupation. - Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the house- hold only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic servico 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 occupatien 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 discase; 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," "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 discases 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 deccased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 322.
No undertaker or other person shall bury a human body . . . until he has received a permit from the board of health or its agent, . . . or . . . from the clerk of the city or town in which the person died; . . . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written statement con- taining the facts required by law to be returned and recorded, which . .. shall be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in lieu thereof a certifi- cate as 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. $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 bodies of only such persons as are supposed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
-.. ...
FOR
CHABASAH NIDAVA
FORM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
37
1 PLACE OF DEATH
County
middleref.
State maso
(City or Town)
37 36
City or Town
St ..... Ward (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Samuel
gervais
(I)in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
darth Chehusbands.
Ward.
(If non-resident give city or town and Statc)
Length of residence in city or town where death occurred
months
years
16 days.
How long in U. S., if of foreign hirth ? Jours
months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Eugene Renard [Gerais)
6 DATE OF BIRTH
act ..
(Month)
19 0 1880 (Day) {Year)
7 AGE
Years
34
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
(h) Name of employer
machinist.
16.
amesbury
Mitral Requatation 6
CONTRIBUTORY
(SECONDARY)
(duration)
S ..
.mos.
......
ds.
18 Where was disease contracted
if not at place of death ?
Lawell Mass
Did an operation precede death ?
no,
não
Was there an autopsy ?
What test confirmed diagnosis ?.
(Signed) James
M.D.
(Address).
127 Cealsalir,
Date
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
(Cemetery)
(City or towns
20 UNDERTAKER Archambaud normal ADDRESS 738
Permit
Official Licen bleck .position.
Date of issne of permit
May 201971
MARGIN RESERVED FOR BINDING
instructions and extracts from the laws on back of certificate.
PARENTS
14
Informant
(Address)
Wordt Clubuland
15 May 20 1921 Justin Lincore 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 Justice R. Man
6-'20. 20,000.
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
The Commonwealth of Massachusetts
12/
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK- THIS IS A PERMANENT RECORD. Every item of information
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
Muay
(Day)
(bear)
17 I HEREBY CERTIFY, That I attended deceased from May 15, 1921 May 18, 1921.
that I last saw her
alive on
May 18, 1921
and that death occurred, on the date stated above, at.
2.30 PM27
The CAUSE OF DEATH was as follows :
If LESS than 1 day ......... hrs. or ........ min. Chimie Interst Nephritis
.. (duration) .ds.
9 BIRTHPLACE (City)
(State or country)
imars
10 NAME OF
FATHER
Kilde gervais
11 BIRTHPLACE OF
FATHER (City)
(State or country)
Canada
12 MAIDEN NAME
OF MOTHER
Dalveria Paulin
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Canada
18
1921
Date of.
Months
7
Days
( Usual place of abodc)
North Glielinyford Stevens Garner
Registered No
....
F
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. Butin many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salcsman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the sccond 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.
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.