USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 15
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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 practicc:
(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.
Form R-305
The Commonwealth of Massachusetts
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
1 PLACE OF DEATH
(ISSUED UNDER THE PROVISIONS OF REVISED LAWS, CHAPTERS 24 AND 29)
County
middlesex
State mass
Registered No. 68
City or Town.
Lowell
Nal (Place of death)
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME ~
alphonse halim
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.,
Ward. No. Chelmsford,
mass
(If non-resident give city or townland State)
months
days
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH Jene
5
( Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows : Sunstrake, Collapsed in wagon on street
(Sec reverse side for additional space)
18 Where was injury sustained if not at place of death ?
(Signed)
Th
mas B. Smith
.M.D.
(Address)
107 Merrimack St.
Medical Examiner for.
the Whist middlesex
June
Date
(Month)
(Day)
( Ycar)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL St. Joseph Chelmsford.
DATE OF BURIAL 1919. (Month) (Day) (Year)
ADDRESS Lowell
21 Burial permit Edvard. 128 firmy issued by
Official
Jonna
Registrar of city or town where death occurred position
1919 (edward), Robins
Filed (Month) (Day) ( Year) Registrar of city or town where deceased resided
9-'18. 10,000.
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information PARENTS
(a) Residence. No (Usual place of abode) Length of residence io city or towo where death occurred 3 SEX 4 COLOR OR RACE male White 5a If married, widowed, or divorced HUSBAND of Cannot by learned 6 DATE OF BIRTH april Month) (Day) 7 AGE 56 Years 1 Months 21 Days If STILLBORN, enter that fact here 8 OCCUPATION OF DECEASED (a) Trade, professioo, or particular kind of work deameter (h) Geoeral nature of industry, which employed (or employer) 9 BIRTHPLACE (City) . nashua (State or country ) 10 NAME OF Joseph. FATHER 11 BIRTHPLACE OF FATHER (City) (State or country) Cana ada 12 MAIDEN NAME OF MOTHER 13 BIRTHPLACE OF MOTHER (City) (State or country ) nada 14 mgp Informant Victor Pali 15 should be carefully supplied. AGE should be stated EXACTLY. MEDICAL EXAMINERS should state CAUSE OF (c) Name of employer Wm Tractor Com. See reverse side for extracts from the laws of the Commonwealth and instructions. DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. business, or establishment in humber
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
15
1863
(Year)
If LESS thao
I day.
........ hrs.
or ........ min.
Thilomene Boule
(Address) 29 Sarah ave Lovell
Filed Jung 7, 1919
210
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
45
Registered No.
(Place of residence)
.St.,
....
Ward
years
2 hrs.
mooths
MARGIN RESERVED FOR BINDING
PERSONAL AND STATISTICAL PARTICULARS
How long in U. S., if of foreign birth? years
1919
6
1919
20 UNDERTAKER a. archambault
22 Date of issue Juve 7, 1919
EXTRACTS
FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE 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 deceased, furnish for registration a stand- ard 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 containing the facts required by law to be returned and recorded, which . . . shall be accompanied by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thercof a certificate as bereinafter provided. If there is no attending physician, or if, for sufficient reasons, bis certificate cannot be obtained early enough for the purpose, or is insuffi- cient, 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 permit is so given and the physician who certifies to the cause of death shall thereafter furnish for registration any other necessary infor- mation 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 examniners shall, in all cases. certify to the city or town clerk or to the city registrar in the place where the deceascd 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 sup- posed 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 supposably 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,
COPIES OF RECORDS OF DEATHS OF NON-RESIDENT DECEDENTS
The clerk of each city and town shall forthwith make certi- fied copies of the records of all . . . deaths recorded during the previous month, if the deceased [was a resident] of any other city or town in this commonwealth or in any . other state at the time of said . . . death, and transmit them to the clerk of the city or town of which such deceased person [was] resident at the time of the said ... death ... and the clerk of a city or town in this commonwealth so receiving such certified copies, or certified copies of .. . deaths, from the clerk of a city or town without the commonwealth, shall record the same. - Revised Laws, Chap. 29, Sec. 13, as amended by Acts of 1910. Chap. 93, Sec. 3.
DESCRIPTION (for unknown person)
...
FORM R-301
MARGIN RESERVED FOR BINDING
2 FULL NAME 3 SEX tale (c) Name of employer 10 NAME OF FATHER PARENTS Informant .. (Address) should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH 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 (b) Generai nature of industry, business, or establishment in wbicb employed ( or employer ).
4 COLOR OR RACE
what
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
marrua
5a If married, widowed, or divorced
HUSBAND of
(Or) WIFE of Charlotte S. Boothby
6 DATE OF BIRTH.
am19-1546
( Month)
( Year)
7 AGE 7 3
Years
Months
Days
If STILLBORN, euter that fact bere
lf STILLBORN, state period of uterogestation.
..... nos.
.........
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Retired
9 BIRTHPLACE (City)
Saco
(State or country)
mama
Joel Beachby
11 BIRTHPLACE OF
FATHER (City)
(State or country)
mamiz
12 MAIDEN NAME
OF MOTHER
Eliza Patterson
13 BIRTHPLACE OF
MOTHER (City) ...
(State or country)
name
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
6
7
1919.
(Year) /
17 I HEREBY CERTIFY, That I attended deceased from 6 - 1-
1919 to 6-6-
19.19
6-6
- .
, 19.19.
and that death occurred, on the date stated above, at.
.
7:30 a.m.
that I last saw h Mnalive on
The CAUSE OF DEATH was as follows : Left Nimipligia
6
... (duration)
... yrs ..
.mos ...
ds.
CONTRIBUTORY.
antonio sclerosis
( SECONOARY)
(duration)
yrs.
mos ..
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
no Date of
Was there an autopsy ?
no.
What test confirmed diagnosis ?
(Signed)
Nhu Ti Ocobona.
M.D.
(Address).
Chrisford
mais
6
-7-1919.
( Month)
(Day)
( Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Edson
Lawere
(City or town)
15 Sime 7 1919 (Edward ), Robbins
(Month) (Day) (Year)
REGISTRAR
21 ] HEREBY CERTIFY that a satisfactory stan-
BEFORE the burial or transit permit was issued Edward ). Robban
Official Than Club position ..
22 Date of issue of burial or transit permit.
DATE OF BURIAL Jeux 9 1919
ADDRESS Torvell.
June 7, 199
10-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Middlesex
State.
mass
City or Town ...
Chelindard
No.
Putman Car
St.
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Tevi Boothbay
(If in the Army or Navy of the United States, give rank, organization, ete.)
(a) Residence. No.
( Usual place of abode)
Length of residence in city or town where death occurred (3
years
Chelinda Centre St.
Ward.
(If non-resident give city or town and State)
days.
How long in U. S., if of foreign birtb ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
months
211
14 Fram. Boottill
Date.
(Cemetery)
20 UNDERTAKER Young & Blake
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS Registered No. 43146
......
(Day)
(Day)
If LESS than
I day, ........ brs.
NITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
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 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.
Statement of cause of death. - Name, first, the DISEASE CAUSING NEATH (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 "Epidemie 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 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" (merely symptomatic), "Atrophy," "Col- lapse," "Coma,""Convulsions,""Debility" ("Congenital,""Senile," ctc.), "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 diseases 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.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE 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 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 frem 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 licu 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 thereafter furnish 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 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.
212
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
(City or town)
Registered No. .......
(Place of death)
Registered No. 119
(Place of residence)
City or Town ....
Springfield
......
......
No ..
20 Lenox street
St ... 7
. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Florence S. Hartshorn
(a) Residence.
State
(Usual place of abode)
Length of residence in city or town where death occurred
years
4
months
(If in the Army or Navy of the United States, give rank, organization, etc.) City or TowChelmsford Centre
St.
days
How long in U. S., if of foreigo birth?
years
months
days
PERSONAL AND .STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) June 13
17
I HEREBY CERTIFY, That I attended deceased from
March ..... 21
:, 199, to June 13-
..........
191.9
that I last saw her
alive on
June 12
191 9
and that death occurred, on the date stated above, at
8 p.
.m.
The CAUSE OF DEATH* was as follows :
* 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.)
Acute Uremia
.....
.... (duration)
... yrs ..
mos
12ds.
CONTRIBUTORY
Chronic Interstitial
(SECONDARY)
Nephritis
(duration)
... yrs. ................ mos .....
ds.
18 Where was disease contracted if not at place of death?
11 BIRTHPLACE OF FATHER (city or town) ..
New Ipswich Did an operation precede death? JO
Date of.
(State or country)
New Hampshire
'12 MAIDEN NAME OF MOTHER Ann E. Barker
13 BIRTHPLACE OF MOTHER (city or town) ......
Lowell
(State or country) Mass. ‹ June
Informant Mrs. W. B. Morthron,
- (Address) 20 Lenox street
Lowell Cem. Lowell, Mass.
June 169 19
20 UNDERTAKER
ADDRESS
Cheney D. Washburn Springfield Mass.
MARGIN RESERVED FOR BINDING
1 PLACE OF DEATH County ... Hampden 3 SEX 4 COLOR OR RACE Female White 5a If married, widowed, or divorced HUSBAND of (or) WIFE of 6 DATE OF BIRTH (month, day, and year) 7 AGE 45 Years 6 If STILLBORN, enter that fact here 8 OCCUPATION OF DECEASED PARENTS 14 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 80 that it may be properly classified. Exact statoment of OCCUPATION is very important. See instructions on back (State or country) Mass.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
Nov. 27 1873
Months 16 Days
If LESS tbao
I day, ........ brs. or ....... mio.
(a) Trade, profession, or
particular kiod of work ...
Buyer Department Store
(h) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer A. G. Pollard Co.
9 BIRTHPLACE (city or town).
Lowell.
10 NAME OF FATHER Edward Hartshorn
Was there an autopsy ?..
No
What test confirmed diagnosis? Clinical & Laboratory
(Signed) James B. Coming
, M.D.
1 4 191 9Address Chestnut Springfield Mass.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL
15 Filed Jun 20 12 9 File Jily 3, 199 Edward S. Robbins
Registrar of city or town where death occurred
Registrar Wf city or towo where deceased resided
State.
Ma.s.s.
CITY OF SPRINGFIELD.
REVIS 0 : 1.0. 1.
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, 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," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the dutics of the household only (not paid Housckecpers who receive a definite salary), may be entered as Housewife, Houscwork, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spc- 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 DEATII, state occupation at beginning of illness. If retired from business, that faet may be indi- eated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATHI (the primary affection with respect to tiine 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- toncum, ete., Carcinoma, Sarcoma, ete., of.
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