USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1914-1916 > Part 56
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Statement of cause of death. - Namc, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same diseasc. Examples: Cercbro-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 indefinitc); 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," "Scnile," 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 septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing 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 dcad, etc.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
1
(Year)
If LESS than
! day .......... hrs.
.......... min. ?
.
9 BIRTHPLACE
(State or country)
north Chelmsford
10 NAME OF
FATHER
Sabatino Diplofeo
12 MAIDEN NAME
OF MOTHER
Locia Lucci
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
nicola mogeatetta
(Address)
59 Summer St
16 Filed Dec 29, 1916 Edward J Rubbing
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from Dic 28 ..... .
1916 to NEX 22 191 1916 that I last saw ha alive on DEC. 28 6, and that death occurred, on the date stated above, at. m. The CAUSE OF DEATH* was as follows :
Mixincline birth.
11. mov. I lived 40 minutes)
(Duration) / ... yrs. and talent foramin ovale mos. ... ds.
Contributory.
(SECONDARY)
(Duration): .yrs.
.mo's.
.........
ds.
(Signed)
.... M.D.
1916
(Address)
* 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
DATE OF BURIAL St Patricks Cemento Dec 50, 1916
20 UNDERTAKER
ADDRESS
James 16 MLLemoto 70 Gor ham.
fif death occurred in Ja hospital or institution, give its NAME. instead of street and number.]
Sabatina Diploma
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
north Chelmsford mars
(City or town.)
St. :
Ward)
...........
.... Registered No. 64
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec 28
191
(Month)
(Day)
.,
(Year)
1 PLACE OF DEATH no Chelmsford (No. 3 SEX 4 COLOR OR RACE Female Miste · DATE OF BIRTH (Month) (Day) 7 AGE 8 OCCUPATION (a) Trade, profession, or particular kind of work (b) General nature of Industry, business, or establishment in which employed (or employer) ... 11 BIRTHPLACE OF FATHER (State or country) Itty PARENTS 13 BIRTHPLACE OF MOTHER (State or country) Itty important. See instructions on back of certificate. 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 ..... .... yrs. mos. ds.
220
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation 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) 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 occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE 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 ncoplasms); 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 provi- 5 ---- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicidc; 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.
R. 15-8-'15. 100,000.
1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford
(No.
Bridge
St.
Ward)
221
Chelmsford, (City or tow&.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Mary A. Ellis.
[If married or divorced woman or iyidow give maiden name, also name of husband] Mary A. Robbins. Elisha M.Ellis
@RESIDENCE
Chelmsford.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
WIDOWED,
Married.
OR DIVORCED (Write the word)
& DATE OF BIRTH
March
9
18.4.3.
(Year)
(Month)
(Day)
If LESS than
I day .......... hrs.
73
yra. 9 mos 19 ds.
or ......... min. ?
B OCCUPATION
(a) Trade, profession, or
particular kind of work
At Home.
At Home.
9 BIRTHPLACE
(State or country)
Swanville, Men
10 NAME OF
FATHER
John F. Robbins.
bine.
11 BIRTHPLACE
OF FATHER
(State or country)
Me.
12 MAIDEN NAME
OF MOTHER
Sally Junfee
Ne.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Elisha, M. Ellia
(Address) Chelmsford, Mare
16 Filed Sec. 28 , 1916 Edward & Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Tec.
(Month)
(Day)
28
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Dec. 25 , 1916, to
Dec. 28
, 1916
that I last saw her alive on.
Dec. 27
1916
and that death occurred, on the date stated above, at 1.15 Am.
The CAUSE OF DEATH* was as follows :
acute nephritis
(Duration)
1
.mos.
ds.
Contributory ...
(SECONDARY)
...... ...............
..............
.......
mos.
ds.
(Signed)
Olmasatoward.
.F
M.D.
Deer 28
1916 (Address)
........
Chelmsford. mars.
* 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.
19 PLACE OF BURIAL OR REMOVAL
grove
Bemeteris.
Belfast, Men
....
20 UNDERTAKER
groß Healey.
ADDRESS
79 Branch St.
1916- > 3 - 1843-
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
3 SEX demale. 7 AGE (b) General nature of industry. business, or establishment In which employed (or employer) .. PARENTS 13 BIRTHPLACE OF MOTHER (State or country) important. See instructions on back of certificate. 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 ... ........ yrs ...
.....
Registered No. 65
, 1916 ....
........
.. (Duration).
.yrs.
.yrs.
DATE OF BURIAL
Dec. 30, 1916.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation 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) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ctc., 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 occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- DASE 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 Aiseases 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 provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing 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.
R. 15-8-'15. 100,000.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH .............
222 Chelmsford
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Lebidzinski
? FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.
@RESIDENCE
720 Chelmsford
...... Registered No.
66
PERSONAL AND STATISTICAL PARTICULARS
6 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the word)
Single
1916
(Year)
If LESS than
I day .......... hrs.
or ......... min. ?
$ OCCUPATION (a) Trade, profession, or - particular kind of work ..................................................................... ............
9 BIRTHPLACE
(State or country}
320. Chelmsford
........ (Duration)
............. yrs.
... mos.
.... .ds.
Contributory
(SECONDARY)
........
....
... (Duration) ................ yrs. ................ mos. .............. as.
(Signed)
ti & farmer
M.D.
Dec. 8
.......
. 1916 (Address):
......
* 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).
In the
At place
of death.
.. yrs.
.mos.
............. ds.
State ...
............. ....
............ mos ..
ds .............
Where was disease contracted, If not at place of death ?..
Former or usual residence. ........
19 PLACE OF BURIAL OR REMOVAL
Riverside Cemetoz 220. Chelmsford
DATE OF BURIAL
Sept. 25 1916
...........
ADDRESS
Filed.
18
9224. 3
1917 Gerard 9.22
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Seht
25
..... , 1916
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
191
....... ,
to
Sept. 25, 1916
.....
that I last saw h .....
alive on ..
191
.....
and that death occurred, on the date stated above, at 6 9-
.m.
The CAUSE OF DEATH* was as follows :
Stillborn
.....
......
10 NAME OF
FATHER
Michael Lebidzinski
12 MAIDEN NAME
OF MOTHER
Mary Syroka
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
3 SEX ' COLOR OR RACE - " DATE OF BIRTH Selt 25 (Month) (Day) 7 AGE yrs .. 1 (b) General nature of industry, business, or establishment in which employed (or employer) ...... 11 BIRTHPLACE OF FATHER (State or country) Russia PARENTS 1$ BIRTHPLACE OF MOTHER (State or country) Russia (Informant) important. See Instructions on back of certificate. (Address) 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 ....... mos. ds.
I PLACE OF DEATH no. Chelmsford .(No .. ..... .......
St. :
Ward)
...............
...........
...............
20 UNDERTAKER
J. S. Hatton
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation 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) 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 houschold 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 (rctircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cercbro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fcocr (never rc- 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 provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing 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 dcad, etc.
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