USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 27
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Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and eausation), 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, peritonacum, ete., Carcinoma, Sar- coma, etc., of ... ............ .... (name origin: "Canecr" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, ete. The eontributory (seeond- ary or intereurrent) affeetion need not be stated unless im- portant. Example: Mcasles (disease eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age,". "Shoek," "Uraemia," "Weakness," etc., when a definite disease ean be aseertained as the eause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State eause for which surgieal 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 violenee, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
2. Deaths supposedly eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, 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 eircumstanees unknown, as A person found dcad, ete.
R. 15. 1-'17. 100,000.
-
MARGIN RESERVED FOR BINDING
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
WORCESTER,
1 PLACE OF DEATH
County ..
WORCESTER.
State
Township
.. or Village ..
.. or
City
WORCESTER
No.Worcester State Hospital
St., .....
........
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Elizabeth G Clark
-
--
St.,
..... Ward.
(If non-resident give city or town and State)
Length 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
3 SEX
Female
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 (month, day, and year) Aug 3 1853
7 AGE
Years
-
Months
64
6
Days
22
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
teucher
(a) Trade, profession, or
particular kind of work ...
(b) General nature of industry,
business, or establishment in
which employed (or employer).
(c) Name of employer
-- Ga.
9 BIRTHPLACE (eity or town)
(State or country)
10 NAME OF FATHER
Joseph G
PARENTS
11 BIRTHPLACE OF FATHER (eity or town) .. (State or country) - - Me.
12 MAIDEN NAME OF MOTHER Sarah \ Cressey
13 BIRTHPLACE OF MOTHER (eity or town).
(State or country)
-- Mass.
14
Informant
Hospital records
worcester
(Address)
15 Filed Mur 4 1918/10
REGISTRAR
18 Where was disease contracted
if not at place of death ?
Did an operation precede death? 110
Date of ..
Was there an autopsy ?.
ves
What test confirmed diagnosis ?
au tonsy
(Signed) ...
Marie . Lindsay
M.D.
-- , 19
(Address)
Torcest er
* State the DISEASE CAUSING DEATHI, 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 spacc.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Riverside Cem.Chelmsford
DATE OF BURIAL
Fel 28
18
19
20 UNDERTAKER
GIO SESSIONS SUNS CO
ADDRESS
WORCESTER
19 18
17
I HEREBY CERTIFY, That I attended deceased from
July18
, 19 17, to ...
Feb 25
19 18
that I last saw he ......... alive on
...... , 19
Fel 25
19
18
and that death occurred, on the date stated above, at ......
2.05Pm.
.. m.
The CAUSE OF DEATH* w
was as follows :
Pulmonary tuberculosis
(duration)
unknown
.... yrs ...
mos ...............
... ds.
CONTRIBUTORY.
Dementia praecox
(SECONDARY)
.(duration)
.... yrs ..
.mos ..
ds.
(City or town)
20
Registered No.
Chelmsford
(a) Residence. No
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Fer 25
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and Am ican 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 cach 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- 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," 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, Houscwork, or At home, and children, not gainfully employed, as At school or At homc. 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nonc.
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: Cerebrospinal fever (the only definite synonym is "Epidemic 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_
(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: Mcasles (disease causing death), 29 ds .; 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," "Senile," 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 diseases resulting from child- birth 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 carbolic acid - probably suicidc. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committec 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 15, 1-'18. 10,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Chelmsford. (City or town)
1 PLACE OF DEATH Miller's
County.
Township
Chelmsford.
State
or Village ... 3rd are
St ..
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Cha
harlee Heure House
(a) Residence.
No .....
3~ ane, Homestead St.
(Usual place of abode)
Length 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)
Married
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH (month, day, and year)
Mar. 20, 18 /5
Years
-
Months
Days
11
If LESS than
I day, ........ hrs.
or ........ min.
Cerebral Embolism.
8 OCCUPATION OF DECEASED
farm
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
East Window
10 NAME OF FATHER Septaries, House
11 BIRTHPLACE OF FATHER (city, or town) E Windear (State or country) leon.
12 MAIDEN NAME OF MOTHER Martha Cellen
13 BIRTHPLACE OF MOTHER (city of town) E. Windhear (State or country) Cours.
14
Informant
Mrs. C. H. House
(Address)
15 Iran. 5 1918 Edward & Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Ich, 3rd
19/§
17
I HEREBY CERTIFY, That I attended deceased from
nor. 30
1918, to Mich. 3rd
.. 1918
Mch. 2 nd
that I last saw hun alive or
...... 1918.
and that death occurred, on the date stated above, at 8.15 a. m. The CAUSE OF DEATH* was as follows:
Recurrent attacks
(duration)
2
... yrs ..
.mos ..
ds.
CONTRIBUTORY
(SECONDARY)
Simile
:(duration)
.yrs ..
... mos ..
ds.
18 Where was disease contracted
if not at place of death ?
X
Did an operation precede death? no, Date of X
Was there an autopsy ?.
110.
What test confirmed diagnosis ?.
observation
Signed)
Umasa Stoward
II.D.
3/4, 19/8 (Address)
Chelmsford Mass.
* 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.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
Edron Cem, Lowell, Marc Mar. 6 19 18
ADDRESS
File
City
2 FULL NAME
3 SEX
7 AGE
72
(a) Trade, profession, or
particular kind of werk ..
PARENTS
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
(State or country)
MARGIN RESERVED FOR BINDING
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
79.
Registered No. 21
...... or
No.
... ,
.........
.. Ward.
(If non-resident give city or town and State)
20 UNDERTAKER
Walter Perham, Chelmsfordes
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of oceupa- tion is very important, so that the relative healthfulness of various pursuits ean 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- itor, Architect, Locomotive cngincer, Civil engineer, Stationary fircman, ete. 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) Forcman, (b) Automobile factory. The ma- terial 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 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. It 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 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 time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopncumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, 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; Chronie interstitial nephritis, ete. The contributory (secondary or inter- eurrent) affection need not be stated unless important. Example: Measles (disease causing death), 29 Gs .; 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," "Senile," etc.), "Dropsy," "Exhaustion,"
"Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease ean be ascertained as the eause. Always qualify all diseases resulting from child- birth 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 hcad - nomicide; Poisoned by carbolic 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." (Recommendations on statement of eause of death 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 Medieal Examiners:
1. Deaths following injury or violenee, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
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 eircumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
1
R 15. 1-'18. 100,000.
MARGIN RESERVED FOR BINDING
1 PLACE OF DEATH
County ....
Malin
Township
Chelmsford
City
(Usual place of abode)
Length of residence in city or town wbare death occurred
years
3 SEX
4 COLOR OR RACE
71
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
Months
Days
2
6
70
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
- at home
9 BIRTHPLACE (city of town) So. Actor
PARENTS
14
Catherine Guen
Informant
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
(State or country)
Mais.
of certificate.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Mch. 5%
1918
17
I HEREBY CERTIFY, That I attended deceased from
Feb. 26
., 19.18, to
mch 50
.,19.1 ¢
Mch. 5th
that I last saw her alive on
...
............ , 19.1.8-
and that death occurred, on the date stated above, at 3 0.
.... m.
The CAUSE OF DEATH* was as follows :
Interstitial nephritis
F
Unknown (duration)
CONTRIBUTORY
(SECONDARY)
(duration)
.yrs ..
.mos.
ds.
18 Where was disease contracted
if not at place of death ?
×
Did an operation precede death? no, Date of X
Was there an autopsy ?.
Urinalysis"
$6
, 19/8 (Address)
Chilorchard Maso.
M.D.
* 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. (Sce reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Powell lemeting
DATE OF BURIAL Mich. 9
1918
File Mar. 9. 1918 Edward Y. Robbing
- REGISTRAR
Chelmsf
80 sfund (City or toan)
State Mass,
Registered No. 22
leentré
..... or
or Village.
Billerica Rd
St ..
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Nancy Haywood (Fletcher) Ingham.
(a) Residence.
No. Billig Ord.
.St.,.
, ......
Ward.
(If non-resident give city or town and Statc)
months
days
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE
$ William A. Ingham
If LESS than
1 day, ........ lırs.
or ........ min.
10 NAME OF FATHER Daniel Fletcher
12 MAIDEN NAME OF MOTHER Ruth Dole
actor
13 BIRTHPLACE OF MOTHER (city or town) ...
(State or country)
Mace.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, 15 N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (h) General nature of industry, business, or establishment io which employed (or employer) ... (c) Name of employer
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
No.
months
days.
How long in U. S., if of foreign birth ?
years
ADDRESS
20 UNDERTAKER
Walter Terhany Chelmsford.
.. yrs ..
.mos ..
ds.
11 BIRTHPLACE OF FATHER (city or town) Acton
What test confirmed diagnosis ?..
(State or country)
Mais
(Signed).
Umasa Howard
(Address)
Chelmsford Mars.
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. -- Preeise 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, Compos- itor, Arehiteet, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, espceially 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 necded. 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 reecive 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 domestie service for wages, as Servant, Cook, Housemaid, etc. It the occupation has been changed or given up on aeeount of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- eatcd thus: Farmer (retired, 6 yrs.). For persons who have no oeeupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same discase. 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; Bronehopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, 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, ete. The contributory (secondary or inter- current) affeetion need not be stated unless important. Example: Measles (disease causing death), 29 &s .; Broneho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (mcrely symptomatic), "Atrophy," "' "Col- lapse," "Coma," "Convulsions,"""Debility" (“Con-
genital," "Senile," ctc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," ete., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting fromn child- birth 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 sueh, if impossible to de- termine definitely. Examples: Aecidental drowning; Struck by railway train - accident; Revolver wound of head - nomicide; Poisoned by earbolic 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." (Reeominendations on statement of cause of death 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, ete.
2. Deaths supposedly eaused by violenee, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized discasc, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under eircumstances unknown, as A person found dead, ete.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County middlesex
State massachusetts
.. Registered No .... 23
Township City Lowell
....... or Village ....
No Lowell Corp. Hospital St. 6
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME albert Patenaude
St.,
.Ward.
no. Chelmsford mass
(a) Residence. No (Usual place of abode) Length of residence in city or town where death occurred
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