USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 19
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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
July
28
1919
(Year) (
17
I HEREBY CERTIFY, That I attended deceased from
July 27
, 19/9, to
July 28
... , 1919
that I last saw hatte alive on
July 28, 1919.
and that death occurred, on the date stated above, at 7 a.m.
The CAUSE OF DEATH was as follows :
Congenital Spina Bifida
/ duration)
.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? To Date of X
Was there an autopsy ?
no
hat test confirmed
(Signed)
Umasa toward
M.D.
(Address)
Date ..
2.8! 1919.
(Month) (Dav) (Year)/
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Sh labricks
(Cemetery)
20 UNDERTAKER
ADDRESS off Erhow
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issned. Edward J. Robbing
Official Corn Click ..... position.
22 Date of issue of burial or transit permit July 28/ 19/19
MARGIN RESERVED FOR BINDING
10-'18. 100,000.
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED, (write the ford)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
July (Month)
27
1918)
(Year) {
7 AGE
Years
Months
Days
5
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation .. ....... mos.
If LESS than 1 day, 9 hrs. or ....... min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work ... (h) General nature ofindustry, business, or establishment in which employed ( or employer) ...
(c) Name of employer
9 BIRTHPLACE (City) (State or country) (Massachusetts
10 NAME OF FATHER
Frid Kelly
PARENTS
11 BIRTHPLACE OF FATHER (City)
Jocurile
(State or country) Massachuset
12 MAIDEN NAME OF MOTHER mary McGillian
13 BIRTHPLACE OF MOTHER (City) (State or country)
& betheling ford massachusetts
14 Fred Kelly
Informant .. (Address)
15 Only 28, 1919 Edward & Robbins
Filed . (Month) (Day) (Year)
/REGISTRAR
DATE OF BURIAL Lowell July 2 2019 (City of town)
2 FULL NAME
Never meckt Vrads
Ward.
(If non-resident give city or town and State)
Klonth)
(Day)
3 SEX
Incele Odete
(DE)
None
-
STANDARD CERTIFICATE OF DEATH
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. C.
Statement of occupation. - Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. The question applics 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) Salcsman, (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 arc 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 DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same diseasc. 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, ctc. 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," etc.), "Dropsy,""Exhaustion,""Heartfailure,""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.
.
1
1
€
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 agc, 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 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 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 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH/
County ...
Hedef
Township
Chelmsford
..... or Village ...
or
City
No.
St., ..............
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Jolin Peasley Jugalle
(If in tho Army or Navy of the United States, give rank, organization, ete.)
(a) Residence.
No.
Chelmsford Hlas
........
(Usual place of abode)
Length of residence in city nr 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)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year) June 51919
/ Months
23 Days
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
·
-
9 BIRTHPLACE (city or town).
Towels
18 Where was disease contracted
if not at place of death?
Did an operation precede death?
no
Was there an autopsy ?.
200.
7
What test confirmed diagnosis ?...
Autumn 9.
Scolona
M.D. /
(Signed)
.......
-5/19 1Q(Address)
* 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. (Seo reverse sido for additional space.)
Informant
Sei H Sugalla
(Address)
Chelmsford
15 July 29, 1919 Edward. Kaffe
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) July 28, 1919
17 HEREBY CERTIFY, That I attended deceased from June 5 1919, to July 29, 1919.
that I last saw him alive on
......... .. ,
1919. 1
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows : Inanition-
(duration)
.. yrs.
mos ....
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
........... yrs ..
.mos.
ds.
Date of ...
10 NAME OF FATHER
Benge H. Ingalle
11 BIRTHPLACE OF FATHER city or town) ..
(State or country)
Thugabono mars
12 MAIDEN NAME OF MOTHER agnes Deadly 13 BIRTHPLACE OF MOTHER (city of town) No Sandwich (State or country)
MARGIN RESERVED FOR BINDING
2 FULL NAME 3 SEX male 7 AGE 0 Ycars (a) Trade, profession, or particular kind of work. (State or country) PARENTS 14 of certificate. 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 (b) General nature of industry, business, nr establishment in which employed (or employer) . (c) Name nf employer
.........
(City or town)
Registered No. 5%
State.
......
Mass
222 Chelmsford
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Pine Ridge Cem.
DATE OF BURIAL
July 29
19 19
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
....
St.,
.........
.Ward.
-..
(If non-resident give eity or town and State)
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved By U. S. Census and American Public Health Association!
Statement of occupalles, -
vi
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," 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. 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 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, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (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- 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. ª 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 (c. g., sepsis, tetanus) may be stated
1
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, 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. 10-'18. 5,000.
1
FORM R-303
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, CHAPTER 24)
State
mars
.
City or Town
Cheveuxford
No
war ford road
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(a) Residence.
No. 14 Court
St.,
Ward,
( If non-resident give city or town and State)
(Usual place of abode)
Length of residence in city or town where death occurred
years
wonths
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)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
-
( Month)
(Day)
Months 25 Days
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation
months
If LESS than 1 day, ...... hrs. or ....... min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work .. (b) General nature of industry,
Parkway Mail Clerk
Chelifatura
9 BIRTHPLACE (City).
(State or country)
mark.
10 NAME OF
Henry S, Perhave
FATHER
11 BIRTHPLACE OF
FATHER (City ) ...
(Statc or country)
Chelmsford
12 MAIDEN NAME
OF MOTHER
Estelle , Kittredge
13 BIRTHPLACE OF
MOTHER (City).
Chelmsford
(State or country)
(Address)
Chelmsford
15
July 22, 1919 Edward 9. Robbins
1 .....
(Month) (Day) (Year)
REGISTRAR
21 Burial permit Edward & Robbing issued by.
Official position.
Tout, click 22 Date of issue
July 221/9 Permit
DATE OF BURIAL July 231919 Month) (Day) (Year)
(Cemetery)
(City or town)
ADDRESS
20 UNDERTAKER
Jahr a Wenbeck Faul
/(Month)
(Day)
1919
( Year)
19 PLACE OF BURIAL, CREMATION, or REMOVAL
Horafathers
Chelmsford
M.D.
(Signed)
(Address).
107 Warringack howell
Medical Examiner for.
Date ..
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
found dead
(Month)
July
20
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: Vietat shot would of trade Suite
nu melan cholic.
(See reverse side for description for unknown person)
MARGIN RESERVED FOR BINDING
1-18-'19. 25,000.
County 3 SEX male 6 DATE OF BIRTH 7 AGE 42 Years PARENTS 14 Informant. should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms, Filed N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information for extracts from the laws relative to the return of certificates of death. so that it may be properly classified under the International Classification of Causes of Death. See reverse side business, or establishment in which employed (or employer)
223
Registered No ..
58
2 FULL NAME
David Varhany
(If in the Army or Navy of the United States, give rank, organization, etc.)
25
1877
(Year)
(c) Name of employer
US Postal Sept.
18 Where was injury sustained
if not at place of death ?..
whomary J. truth
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 deccased, 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 eauscs 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 state- ment containing the facts required by law to be re- turned 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 herein- after 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 permit 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 elerk 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 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 in- jury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause, the nature of an injury and of its consequences; and (2) under manner, the mode of its production together with the circumstances when these are known. For example:" "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a steam railway accident." "Pistol shot wouna of the chest with associated hemorrhage, homi- cidal." "Asphyxiation by suspension, suicidal." "Syn- cope while under the influence of ether administered as a surgical anæsthetic." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If investigation shows the death to have been due to dis- ease, specify: (1) Under cause, its known or presumable nature; and (2) under manner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous, of the brain (basal gangloid) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
DESCRIPTION (for unknown person)
NOTICE TO UNDERTAKERS : No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have come to his death by violence, until a permit in writing, signed by the Medical Examiner, has first been obtained. - Revised Laws, Chap. 24, Sec. 20.
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