Deaths 1919, Part 18

Author: Chelmsford (Mass.)
Publication date: 1919
Publisher:
Number of Pages: 188

USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 18

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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 "Epidemic 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 repert mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Wcakness," etc., when a definite disease can be ascertaincd as the cause. Always qualify all discases 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. 329.

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 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 lieu 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 thereafterfurnish 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 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 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.

Form R-305

The Commonwealth of Massachusetts

MEDICAL EXAMINER'S CERTIFICATE OF DEATH

OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS

1 PLACE OF DEATH

(ISSUED UNDER THE PROVISIONS OF REVISED LAWS, CHAPTERS 24 AND 29)

County

middlesex

State,

masA).

Registered No. 1005

City or Town Lowself

(If death occurred in a hospital or institution, give its NAME Instead of street and number)

2 FULL NAME John Clecon

(a) Residence.

No. Riberneck Rd

(Usual place of abode)

(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 hirth?

3 years

months

days

PERSONAL AND. STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

July 8

1919

(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 : Punctured Wound of neck

Withlaceration of Left Superior Thyroid artery accidental Fall on Pitchfork while getting hay in barn loft to feed horse.)

(See reverse side for additional space) 18 Where was injury sustained RiverneakRf.Chelmel if not at place of Those Smit

ford

...... , M.D.

(Address). 10? Merrimackst. howell Medical Examiner for . sethilist, middleserio. July 10 1919

(Month)

(Day )

( Year)

19 PLACE OF BURIAL, CREMATION, OR REMOVAL Wistlawn howell

DATE OF BURIAL, uly 11,1 !! (Month) (Day) (Year)

AADDRESS 20 UNDERTAKER Saunders Lowell

Informant. Carl an Strandberg

(Address) Chelmsfordtomass 8

Filed July 11, 9 Kesk

Registrar of city or town where death occurred July 30 1919 Edward &Robbing

Filed (Month) (Day) (Year) Registrar of city or town where deceased resided

9-'18. 10,000.

should be carefully supplied. AGE should be stated EXACTLY. MEDICAL EXAMINERS should state CAUSE OF

3 SEX 7 AGE (b) General nature of industry, PARENTS 14 15 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 which employed (or employer)

5a If married, widowed, or divorced HUSBAND of (or) WIFE of Years Months Days 5g If STILLBORN, enter that Fact here 8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work. Farmhand (c) Name of employer Carl Strandberg 9 BIRTHPLACE (City) 0 (State or country) Sweden. 10 NAME OF (Signed). FATHER @lafalecom Date ... 21[ Burial permit issued by Official position 22 Date of issue N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information .........

5 SINGLE, MARRIED, WIDOWED, OR

DIVORCED (write the word)

6 DATE OF BIRTH

Cannot be learned

(Month)

(Day)

(Years

If LESS than 1 day ......... hrs. or ........ min.

11 BIRTHPLACE OF FATHER (City)

(State or country) Sweden

12 MAIDEN NAME

OF MOTHER Christina anderson

13 BIRTHPLACE OF MOTHER (City)

(State or Sweden

Registered No.

A (Place of residence) a St., Ward

No. O.t. et torno

(If in the Army or Navy of the United States, giye rank, organization, etc.)

Ward Chelmsford

mass

....

2.1 (Place of death)

-0

2/09

16 DATE OF DEATH

(Month)

4 COLOR OR RACE

male white Single

MARGIN RESERVED FOR BINDING

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. S22.

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 thereof a certificate 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 insuffi- eient, 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 examiners shall, in all cases, certify to the city of town clerk or to the city registrar in the place where the deceased dird. 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 eare during a last illness from disease unrelated to any form of injury.

(2) Board of Health physicians will certify to sueh 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. ---- Remixed Laws, Chap. 29, Sec. 13, as amende' by Acts of 1910. Chap. 93, Sec. 3.

DESCRIPTION (for unknown person)

...

FORM R-301

The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH

220

OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS

1 PLACE OF DEATH

County ............ Middlesex

State Mass

Registered No. 50

City or Town Che Imsford

No.Russell .. Mill ..... Road

St.

Ward

(If death occurred in a hospital or institution, give its NAME instead of street and number)

2 FULL NAME

Josephine.A ..... Mavor ...

( If in the Army or Navy of the United States, give rank, organization, etc.)

St.

Ward.

(If non-resident give city or town and State)

Leogtb of residence in city or town wbere death occurred

years

months

days.

How long io U. S., if of foreign birth ? 30

years

mooths

days

PERSONAL AND STATISTICAL PARTICULARS

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

Oct ( Month)

(Day)

( Year)

Months

Days

If LESS than

1 day. ....... brs.

If STILLBORN, state period of uterogestation mos.

of ..... min.

8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work .. Cloth Inspector

(b) Georral nature of industry,

business, or establishmeot io

Woolen mill

Sterling Mills

Sweden

May or

11 BIRTHPLACE OF FATHER (City ). Commit de learned

12 MAIDEN NAME OF MOTHER /

.....

Informant Henry Pearson

(Address) Chelmsford, Mass

15 July 27, 1919, Edward J. Rolling (Month) (Days ( Year) REGISTRAR

21 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued. Edward J, Kolbus

Official -... position

22 Date of issue of burial or transit permit

DATE OF BURIAL

(Cemetery)

(City or town)

ADDRESS

20 UNDERTAKER Imgthunders

Varia Check 22

July 21, 1919

MARGIN RESERVED FOR BINDING

3 SEX Female 6 DATE OF BIRTH 7 AGE 77 Years 9 9 BIRTHPLACE (City) (State or country) 10 NAME OF FATHER (State or country) 13 BIRTHPLACE OF MOTHER (City) . (State or country) PARENTS 14 should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH which employed ( or eorployer ) ... Filed 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 If STILLBORN, coter that fact bere

10-'18. 100,000.

MEDICAL CERTIFICATE OF DEATH

16 DATE OF DEATH

(Month)

July

25 1919

(Day)

(Year)

17 I HEREBY CERTIFY, That I attended deceased from about /8 hot to July 2d 1919. that I last saw her alive on July25, 1919. and that death occurred, on the date stated above, at 3 P

m. - The CAUSE OF DEATH was as follows :

(Urteria

....

( duration) fer 10

yrs ......

mos .... ds.

CONTRIBUTORY atd af

(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 ?

(Sigoed)

719. Nach

, M.D.

(Address) 40 rondellen+

Date

21 1919

(Monthi)

( Day)

(Year) /

19 PLACE OF BURIAL, CREMATION, OR REMOVN neredge

(a) Residence. No. Russell Mill Road ..

(Usual place of abode)

REVISED UNITED 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 cvery 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 fircman, 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 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 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.). Tor 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: Cere- brospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid usc 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 (discase 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," etc.), "Dropsy,""Exhaustion,""Heart failure," "Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can be ascertaincd 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

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 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 lieu 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 certifics 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 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 practice:

(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside carc during a last illness from disease unrelated to any form of injury.

FORM R-301

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

The Commonwealth of Massachusetts

22/

OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS

1 PLACE OF DEATH (

County ..

State

(Massachusetts 56

City or Town ...

& Chelmsford

Diver Meek Road

St.

Ward

(If death occurred in a hospital or institution, give its NAME instead of street and number)

Kelly

(If in the Army or Navy of the United States, give rank, organization, etc.)

(a) Residence. No.

(Usual place of abode)

Length of residence in city or town where death occurred

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Deaths 1919, Part 18

Author: Chelmsford (Mass.) Publication date: 1919 Publisher: Number of Pages: 188

Author: Chelmsford (Mass.)
Publication date: 1919
Publisher:
Number of Pages: 188