USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1917-1918 > Part 42
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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
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affeetion with respect to time and eausation), using always the same accepted term for the same disease. 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; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, ete., Carcinoma, Sarcoma, ete., 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 eausing death), 29 Gs .; Broneho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "Col- lapse," "Coma," "Convulsions,"" "Debility" ("Con-
genital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shoek," "Uremia," "Weakness," ete., when a definite disease ean be aseertained as the eause. Always qualify all diseases resulting from ehild- birth or misearriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State cause for which surgical operation was undertaken. For VIOLENT DEATIIS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably sueh, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - 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 Nomenelature 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, Homieide, etc.
2. Deaths supposedly caused by violenee, 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, ete.
1
4. Deaths under eireumstanees unknown, as A person found dead, etc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
-
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.
1 PLACE OF DEATH
County ..
middlesex
City
.
(a) Residence. No ...
0
(Usual place of abode)
Length of residence in city or town where death occurred
years
3 SEX
4 COLOR OR RACE
white
male
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
81
Months
/
8 OCCUPATION OF DECEASED
(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
13 BIRTHPLACE OF MOTHER (city or town).
PARENTS
(State or country)
mass.
Informant
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
(State or country)
mars
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
of Laura S. Hodgman.
Days
15
If LESS than
1 day, ........ hrs.
or ........ min.
Retired
9 BIRTHPLACE (city or town)
Carlule
10 NAME OF FATHER
Jasiah Hodgman
11 BIRTHPLACE OF FATHER (city or town) Merchche (State or country)
12 MAIDEN NAME OF MOTHER Qual Shouldund -19 (Address) Non Chalfond ues.
T. Banlage
14 Laura O. Moodyman
(Address)
632 Wichard Se Lowell
15
File Oct. 6, 1918 Edward . Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Cano
19/8
17
I HEREBY CERTIFY, That I attended deceased from
Oel. 1
1918, to
. 1918.
Del. -
that I last saw h ....
alive on
....... 1948
and that death occurred, on the date stated above, at
8:30 P.
.m.
The CAUSE OF DEATH* was as follows :
(duration) wessel
...... 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?
Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
75, Varney
I.I.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. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Lowell (emitu)
DATE OF BURIAL Den 8 19/8
20 UNDERTAKER
20132 Wer Chelmsford (City or town)
Registered No. 74
Township
Ness Chelmedard
.. or Village
or
No.
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
Benjamin Hodgman
St.,
Ward.
(If non-resident give city or town and State)
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
months
MARGIN RESERVED FOR BINDING
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
State
mass
ADDRESS
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH e,+ + J. S. Census and American 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 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, Architeet, 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 linc 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 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 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 oeeupation at beginning of illness. If retired from business, that faet 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 aceepted term for the same disease. Examples: Cerebrospinal fever (thc 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, ete., Carcinoma, Sarcoma, ete., 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 .; Broneho- 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 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 carbolie 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 eausc 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 Mcdieal 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, ete.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
1
The Commonwealth of Massarinisetts STANDARD CERTIFICATE OF DEATH
133
(City or town)
1 PLACE OF DEATH
County.
maleo
State
mars.
Registered No. 75
Township
Chelmnoford
... or Village.
.... or
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Harriet Maria Perham
(a) Residence.
No. Weetting Good
(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
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Oct. 6
19 / 8
17 I HEREBY CERTIFY, That I attended deceased from Sikt. 26, 1918 to Det. 6 , 1918
that I last saw hal
alive on
.. 1918
and that death occurred, on the date stated above, at
.. m.
The CAUSE OF DEATH* was as follows :
Epidemia Influenza
(duration)
.. yrs.
mos ..
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
... yrs ..
.mos.
10
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 ?
(Signed).
II.D.
- 62, 19' (Address)
* State the DISEASE CAUSING DEATH, ofAn 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 Alatt Toud Cem.
DATE OF BURIAL 0
19/8
ADDRESS
20 UNDERTAKER
Walter Tenham Chickensfund
MARGIN RESERVED FOR BINDING
3 SEX Female 7 AGE Years 36 (State or country) PARENTS Informant (Address) 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, of certificate. N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
4 COLOR OR RACE
Wiele
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
marcial
5a If married, widowed, or divorced HUSBAND of (or) WIFE finalde. Turhan
6 DATE OF BIRTH (month, day, and year)
Months
11
Days
21
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Housewife
9 BIRTHPLACE (city or town) Jemkle N.H
10 NAME OF FATHER Henry H (Emerson
11 BIRTHPLACE OF FATHER (city or town) Chelmsford (State or country) mars.
12 MAIDEN NAME OF MOTHER louise (handbalat)
13 BIRTHPLACE OF MOTHER (city or town) Temple (State or country)
14 Mr. a. C. Pulicu
15 Oct. 8. 1918 Eduard Whatbourg REGISTRAR
....
St.
Ward
City
No.
St.,
Ward.
(If non-resident give city or town and State)
-
nonca
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupatich. i recise 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 necdcd. 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 laborcr, Farm laborer, Laborer - Coal minc, etc. Women at home, who are engaged in the duties of the houschold 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 tiinc and causation), using always the same accepted terin for the saine discase. Examples: Cerebrospinal fever (thc 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 (sccondary or inter- current) 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" (mcrely symptomatic), "Atrophy," "Col- lapse," "Coma, "Convulsions," "Debility" ("Con-
genital," "Senile,"
etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Wcakness," etc., when a definite disease ean 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 dc- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - nomicide; Poisoned by earbolic aeid - 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 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, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ctc.
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. 100,000.
-- 1
134
(City or town)
1 PLACE OF DEATH holdlead
County
State.
Iltaxu.
Registered No. 76
Township ..
City
No.
St ..
Ward
(If death occurred In a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
About autor.
St., ................ Ward.
(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
3 SEX
Male
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
2 Harried
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Ycars 26
Months
7
Days
7
If LESS than
I day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(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
9 BIRTHPLACE (city or town)
(State or country)
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
12 MAIDEN NAME OF MOTHER Emily Sanford.
13 BIRTHPLACE OF MOTHER (city or town) Jeme mehr (State or country) .
14 Yh Chrome, "Caster
Informant
(Address) Santora 21/2.
15 Filed ect. 7 . 198 Edward J. Rllung
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Del-7
19 / 8
17
I HEREBY CERTIFY, That I attended deceased from
Del. 3
, 1918 to
19/8
that I last saw h
........ alive on
Out. 7
. 19 /F.
and that death occurred, on the date stated above, at
11.9 m.
The CAUSE OF DEATH* was as follows :
.
(duration)
.yrs .....
.. mos ..
5 ds.
influcaja
CONTRIBUTORY
(SECONDARY)
___ (duration)
... yrs ...
mos ..
6
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 ?...
(Signed)
M.D.
21-7 1918 (Address) untchelas fand mas
* 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
19/>
20 UNDERTAKER
Aurora
e
ADDRESS 14.Jeg Oh
so that it may be properly classifled. 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.
1
:
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
... or Village ....
Ray SL,
or
(a) Residence.
No
(If non-resident give eity or town and State)
MARGIN RESERVED FOR BINDING
PARENTS
1
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Preeisc 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 agc. For many occupations a single word or terin on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architeet, 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," 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 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; 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, cte. The contributory (secondary or inter- current) affcetion need not be stated unless important. Example: Mcasles (disease causing death), 29 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Ancmia" (mercly symptomatic), "Atrophy," "Col- lapse," "Comna,' "Convulsions," "Debility" ("Con- genital," "Senile." etc.), "Dropsy," "Exhaustion," 'Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," ctc., when a definite discase can be ascertained as the causc. 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 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 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, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ctc.
3. Sudden deaths of persons not disabled by recognized discase, 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. 100,000.
135
The Commonwealth of Massachusetts
2 STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATHY alerant County ..
State
.Registered No. .....
77 ....
Township ToWELL
No.
wor Village .........
gratis Rd.
He heatro ford
.or
.St.
, ........
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(a) Residence. No. 1/1 ..... (Usual place of abode) Length of resideoce io city or towo wbere death occurred years
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