USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 37
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Cases for the Medical Examiners. - Under the provisions 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, Ex- posure, etc.
3. Sudden deaths of persons not disahled by recognized disease, as A death upon the strcet, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No
Centre St.
St. :
Ward)
Registered No.
2
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
mala
4 COLOR OR RACE
white
.
6 DATE OF BIRTH
DEC
19 1918
(Month)
(Day)
(Year)
7 AGE
0
yrs.
0
mos.
mos 21
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Lowell Mais
PARENTS
12 MAIDEN NAME
OF MOTHER
Ethel Hadans
13 BIRTHPLACE
OF MOTHER
(State or country)
Lowell
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE?
(Informant)
ExecutadaFlemings
(Address)
Chaletin
in
Filed .. Jan, 10, 1912 Edward Y. Rolling
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jan.
(Month)
(Day)
1912
(Year)
17
I HEREBY CERTIFY that I attended deceased from
8th
191.2, to
...
1912
......
If LESS than
1 day, ....
„ hrs.
that I last saw him .... alive on
Jan 8th
-
, 1912
and that death occurred, on the date stated above, at 120 m.
The CAUSE OF DEATH* was as follows :
Infantile
....
.... (Duration)
yrs.
.mos.
2/ ds.
Contributory
(SECONDARY)
.(Duration)
yrs.
mos.
ds.
(Signed)
masa toward
M.D.
Jan 9, 1912 (Address)
Chelmsford
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ..
yrs.
mos.
ds.
State
.. yrs.
In the
mos.
ds ..
Where was disease contracted, If not at place of death ?
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
Hortathin Con
20 UNDERTAKER
Halter Perham
ADDRESS
Chelmsford
important. See instructions on back of certificate.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
87
Chelmsford (City of town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Howard Brooks Fleringen
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.}
@RESIDENCE
Chelmsford
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
MARGIN RESERVED FOR BINDING
10 NAME OF
FATHER
Harry B Flemings
11 BIRTHPLACE OF FATHER (State or country)
Hepatitis
.
DATE OF BURIAL
Jan 10 1912
....
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive enginecr, 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) Sales- man, (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 household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically 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: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia, Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, 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 (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions 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, Ex- posure, 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.
88
The Conunmmwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Somerville (No .... 385 Highland Avenue St. ;
Ward)
fIf death occurred in a hospital or institution, give Its NAME Instead of street and number.]
FULL NAME William H. Hoole [if married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE North Chelmsford, Mass.
Registered No.
945
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
male
white
6 SINGLE,
MARRIED,
WIDOWED.
OR DIVORCED
(Write the word) married
6 DATE OF BIRTH
April .4
1864
1.
(Month)
(Day)
(Year)
7 AGE
If LESS than I day. ....... hrs.
47
yrs.
7 mos. 27
ds.
Or ....... min. ?
& OCCUPATION
(a)' Trade, profession, or particular kind of work. House Painter
(b) General nature of industry. business, or establishment in which employed (or employer).
9 BIRTHPLACE (State or country)
Lowell, Mass.
10 NAME OF FATHER
Edward P. Hoole
11 BIRTHPLACE OF FATHER (State or country)
Farmington, Maine.
12 MAIDEN NAME OF MOTHER
Jennie R. Watts
13 BIRTHPLACE OF MOTHER (State or country)
Knox, Maine.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Edward P. Hoole
(Address)
Lowell, Mass.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec ........ 1. 1911
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
Sept.
191.1., to.
Dec. 1, . 1911 ,
that I last saw h.im alive on
Dec. 1,
1917
10.35" and that death occurred, on the date stated above, at ... P .. m. The CAUSE OF DEATH* was as follows : Chronic ..... Valvular Heart ....
(Duration) yrs. .... . ..... mos. ds.
Contributory ........ Chronic Nephritis (SECONDARY)
(Duration)
yrs.
mos. ds.
(Signed)
J. Edw. .. Hoole
M.D.
Dec . 1 , 191 1. (Ads) ....... Somerville
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ..
yrs.
.. mos.
In the
ds.
State
... ..
.yrs. .
mos.
ds.
Where was disease contracted, if not at place of death ?.
Former or usual residence .. ..............
1 PLACE OF BURIAL OR REMOVAL
Edson Cemetery, Lowell, Mass.
DATE OF BURIAL .Dec . 4,, 191.1.
ADDRESS
20 UNDERTAKER W.A. Frink
W.Somerville.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
..
...
PARENTS
18 Filed. Dec. 5, 19, 13 Adeus T. C
Somerville (City or town.)
86
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive 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) Sales- man, (b) Grocery ; (a) Forcman, (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 household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically 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: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Łobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- coma, 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 (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," " Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," " Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions 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, Ex- posure, 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.
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