USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 22
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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 ?
(SignedX
auk S Phillips
, M.D.
(Adress) In Cheleng Lands Programme
couro
20 1. 1219
(Year)
Date ..
( Month)
(Day)
PLACE OF BURIAL, CREMATION, OR REMOVAY
(Cemetery)
(City or town)
DATE OF BURIAL 19/ 22/19
20 UNDERTAKER ADDRESS James +0 2om Lous Klowall
.....
Loures
MARGIN RESERVED FOR BINDING
2 FULL NAME
MEDICAL CERTIFICATE OF DEATH
EXTRALI:
·HE
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH.
[Approved by U. S. Census and American Public Health Associai.
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 husiness 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 "Lahorer," "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 he 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 heginning of illness. If retired from husiness, that fact may he 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 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 he 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,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can he ascertained as the cause. Always qualify all diseases resulting from childhirth 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 hy 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.
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 hest of his knowledge and helief the name of the deceased, his supposed agc, the disease of which he dicd [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. 522.
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 ohservance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given hedside care during a last illness from discase unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled hy recognized discase 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-301
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
229 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
Middlesex
State.
Mass
Registered No.
City or Town.
Chelmsford
No.
Chelmsford From farm
St., .......
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(a) Residence. No.
Chelmsford Form Form. St.
( Usual place of abode)
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
40
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Make It trots
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
markil
5a If married, widowed, or divorced
" HUSBAND of
· · · (or) WIFE of
margaret
6 DATE OF BIRTH
Mar. 28. 1832.
( Month)
(Day)
(Year)
7 AGE
87
Years
X
Months
29 Days
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation
.mos.
If LESS than
I day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
(h) Generai nature of industry,
business, or establishment in
which employed (or employer) ..
Hetivid
(c) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
Fireduck Lean
PARENTS
11 BIRTHPLACE OF
FATHER (City)
(State or country)
Cannot he learned
12 MAIDEN NAME
OF MOTHER
Stamich
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
1
Cantik leaved
Date
aug
2 7/ 1919.
......
( Years
( Monthy
(Dayy
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Forral Ct
Gotland
DATE OF BURIAL Lug 2/ 1919
(Cemetery)
(City or town)
20 UNDERTAKER
ADDRESS
15 Quin 27: 19/ Oderand Fro Rolfing.
(Month) (Day) (Year)
REGISTRAR
21 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was hled with me BEFORE the burial or transit permit was issued. Elwar 1, J. R-06mg
Official position
John Clark
Date of issue Of permit ang 2) 199 No
Permit
1-6-'19. 150,000.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Monthly
(Day)
1919.
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
april
1919,
aug. 26 1919
that I last saw hem alive on
aug. 24, 19/19.
and that death occurred, on the date stated above, at.
.. m.
The CAUSE OF DEATH was as follows : Senility
arteriosclerosis
(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? 120. Date of
Was there an autopsy ?
no.
What test confirmed diagnosis ?.....
Autumn 4. Scarance
(Signed).
., M.D.
( Address).
Calorford, mans.
14 In It. Lear
Informant.
(Address)
Bootro Mass.
MARGIN RESERVED FOR BINDING
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 should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
-
(If in the Army or Navy of the United States, give rank, organization, etc.)
Ward.
Portland. Mannen
..... >
(If non-resident give city or town and State)
.......
LA
26.
4 COLOR OR RACE
Carpenter
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Puone Health Association]
Statement of occupation. - Precise statement of occupation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to cach and every person, irrespective of ags. For many occupations a single word or term on the first lins will bs sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stationary fireman, etc. Butin 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 bs used only when needed. As cxamples: (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 tho occupation has been changed or given up on account of the DISEASE CAUSING NEATH, stats 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, ths DISEASE CAUSING NEATH (thic 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. Ths 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,""Senils," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite discase ean bs ascertained 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.
Certifieates 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, hsmorrhage, 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 contractcd, 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 hs has received a permit from the board of health or its agent, .. . or . . from the clerk of the eity 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 thercof a certifi- eats 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 bs obtained as to the deceased, or as to the manner or cause of the death, which ths 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 examinatien upon ths view of the dead bodies of only such persons as are supposed to have come to their death by violencs. - 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 thoss of persons to whom they have given bedside care during a last illness from discase 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 homs when the certificats of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. Thess include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or clectrical agents, and deaths following abertion, but also deaths from dissase 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-301
MARGIN RESERVED FOR BINDING
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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
230 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
Registered No. 1673-
St. .Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(If in the Army or Navy of the United States, give rank, organization, etc.)
(If non-resident give clty or town and State)
months
days
MEDICAL CERTIFICATE OF DEATH
(Day)
-1919
(Year)
17 I HEREBY CERTIFY, That I attended, deceased from
aug 26
, 19/9
that I last saw bm
alive on
Ciny 26
, 1919
and that death occurred, on the date stated above, at.
4 .
... m.
The CAUSE OF DEATH was as follows :
5 hours
yrs ...
mos ...... ds.
(duration)
.. yrs ....
mos .....
ds.
Did an operation precede death ?
Date of
27
1949
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Elinivano
machen
DATE OF BURIAL aug 27 199
ADDRESS
20 UNDERTAKER
young& Blake
Lorocce
al Com club position.
22 Date of issue of burial or transit permit
M.D.
Informant
(Address)
Noltewpad
15
Cum 27, 1919 Edward Job blog
(Month) (Day) (Year)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stao- dard certificate of death was filed with me BEFORE the burial or transit permit was issued( Edward Gr Robbins
10-'18. 100,000.
1 PLACE OF DEATH.
County.
State
mais
City or Town.
Douglas Halu
2 FULL NAME
(a) Residence. No
(Usual place of abode)
St.
Ward.
Length of resideoce io city or towo where death occorred
months
years
days.
How long in U. S., if of foreign birth ?
years
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR QR RACE
male
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
16 DATE OF DEATH
Ceny 26
(Month
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
19
, to.
6 DATE OF BIRTH
Counq 26-1919
(Day)
(Year)
Taronth)
7 AGE
Years
Months
Days
If LESS thao
If STILLBORN, eoter that fact here
+ day, .. .. . hrs.
or ........ min.
If STILLBORN, state period of uterogestation
mos.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work ..
(h) General nature of industry,
business, or establishmeot in
( duration)
which employed ( or employer ) ..
(c) Name of employer
CONTRIBUTORY
(SECONDARY)
9 BIRTHPLACE (City)
(State or country)
18 Where was disease contracted
Harry Haluf
2
if not at place of death ?
10 NAME OF
FATHER
11 BIRTHPLACE OF
FATHER (City).
Was there an autopsy ?
NovaScotia
(State or country)
What test confirmed diagnosis ?.
12 MAIDEN NAME
(Signed)
Hannah Bugge
OF MOTHER
13 BIRTHPLACE OF
(Address) ..
PARENTS
MOTHER (City)
(State or country)
England
Date
( Monthr)
(Day)
14
Harry Haly
(Cemetery)
(City or town)
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
...
REVISED UNITED STATES STANDARD CERTIFIC .. OF DEATH
[Approved by U. S. Census aod 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, 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 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 CAUSINO 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, cte. 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,""Heart failure,""IIemorrhage,""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.)
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