Deaths 1919, Part 23

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

USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 23

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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. 822.

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. - Reviscd 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 persona found dead.

. . .

FORM R-301

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 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

OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS

1 PLACE OF DEATH

County.

Middlesen

State.

Massachuse Registered No.

City or Town.

Chelmsfall.

No.

St. .Ward

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

2 FULL NAME

Oscar- Hanry

Johnson

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

(a) Residence. No.

(Usual place of abode)

Length of resideoce in city or town where death occurred

years

months

days.

How loog in U. S., if of foreigo birth ?

years

months

days

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Mala-

4 COLOR OR RACE

Ihrita

5 SINGLE, MARRIED, WIDOWED, OR

DIVORCED (write the word)

Single

5a If married, widowed, or divorced

HUSBAND of

(or) WIFE of

6 DATE OF BIRTH 2 24 30-

( Month)

(Day)

(Year)

7 AGE

Years

Months& %

Days

If LESS thao

I day, ........ hrs.

If STILLBORN, eoter that fact here

If STILLBORN, state period of uterogestation

.mos.

or ....... min.

8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work. (b) General nature ofindustry, business, or establishment in which employed (or employer) ..

9 BIRTHPLACE (City) (State or country) West Chelmsford- Mars

10 NAME OF

FATHER

Oscar- Colinzon

PARENTS

11 BIRTHPLACE OF FATHER (City ). (State or country) SuEden

12 MAIDEN NAME

OF MOTHER

Amanda. Sonback

13 BIRTHPLACE OF

MOTHER (City)

(State or country)

SuEden.

MEDICAL CERTIFICATE OF DEATH

16 DATE OF DEATH.

(Month)

(Day)

(Year)

I HEREBY CERTIFY, That-I attended deceased from

my 23

19/9, to-

,1919

that I last saw b

alive on

Lucy 26

, 19 49,

and that death occurred, on the date stated above, at 1.9 m.

The CAUSE OF DEATH was as follows :

Centro Stal Memphis

( duration)

yrs ..

ds.

mos ...

CONTRIBUTORY

(SECONDARY)

(duration)

... yrs ..

mos .....

ds.

18 Where was disease contracted

if not at place of death ?

Did an operation precede death ? ...

Date of

Was there an autopsy ?

What test confirmed diagnosis ? ....

(Sigoed)

Fud Edurney

M.D.

(Address)

Date.

anul. 27

1919

( Month)

( Day)

(Year)

Informant

Pacar

Johnson.

(Address)

AN Chilmaland

File (Month)(Day) (Year)

REGISTRAR

20 UNDERTAKER

David L Freigt Son

Wartead

21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued .. Edwardf. Rolling

Official Com clerk . position.

22 Date of issue of burial or transit permit

DATE OF BURIAL aug 29 19/9

ADDRESS

10-'18. 100,000.

19 PLACE OF BURIAL, CREMATION, OR REMOVAL

West Chefmyad Center

(Cemetery)

(City or town)

....

231

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

194

St.,

Ward.

MARGIN RESERVED FOR BINDING

19/9

REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH

casus and American Public Health Association]

Statement of occupation. - Preise statement of occupation is very important, so that the relative healthfulness of various pursuits ean 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, Civil engineer, Stationary fireman, etc. But in many eases, 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- eifically the occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indieated thus: Farmer (retired, 6 yrs.). For persons who have no oeeupation whatever, write None.

Statement of causo 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, ete., Carcinoma, Sarcoma, etc., of .......... (name origin; "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discase; 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 symptomatie), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," ete.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shoek," "Uremia,""Weakness," ete., when a definite disease can be aseertained as the eause. 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- mittec 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, neerosis, 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 elassified 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 elerk 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 elerk, . . . 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 ean 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 eases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residenee, 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 arc 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 ealls for the observance of the following rules of practice:

(1) Attending physicians will certify to sueh 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.

FORM R-301

MARGIN RESERVED FOR BINDING

City or Town. 2 FULL NAME (a) Residence. No. 3 SEX 4 COLOR OR RACE 5a If married, widowed, or divorged HUSBAND of (or) WIFE of July 6 DATE OF BIRTH (Month) 8 OCCUPATION OF DECEASED/ (a) Trade, profession, or particular kind of work. (b) General nature of industry, business, or establishment in which employed (or employer) ... (c) Name of employer 9 BIRTHPLACE (City) (State or country) 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (City) (State or country) 12 MAIDEN NAME OF MOTHER 13 BIRTHPLACE OF PARENTS MOTHER (City) ... (State or country) 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 If STILLBORN, enter that fact here If STILLBORN, state period of uteregestation ....... mos.

STANDARD CERTIFICATE OF DEATH

1 PLACE OF DEATH fiedlerce County ...

Registered No.

St.,.

... Ward

(INdeath occurred In a hospital or institution, give its NAME instead of street and number)

John J. M & Cnancy

Hf in the Army øy Navy of the United States, give rank, organization, ete.)

( Usual place of abode)

Length of residence in city or town where death occurred

years

months

days.

How long in U. S., if of foreign birth ?

years

months

days

PERSONAL AND STATISTICAL PARTICULARS

SINGLE, MARRIED, WIDOWED, OR

DIVORCED (write the worn)

WidowEd.

alice M' Grace

29. 1858 (Day) (Year)

7 AGE

6 Years

Months

Days

If LESS than

1 day, ........ hrs.

......... min.

chiarire Valvular prince of Heart

.(duration)

.yrs ..

.mos ...

ds.

CONTRIBUTORY Michalis

(SECONDARY)

(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 ?

What test confirmed diagnosis ?

(Signed)

(Address) ..

two chili

, M.D.

1919

(Month)

(Day)

(Year)

LE OF BURIALA CREMATION, OR REMOVAL

DATE OF BURIAL

19 /20 . Patrick forwell.

(Cemetery) ({ity or town)

20 UNDERTAKER

two Molloy

ADDRESS bowcel.

Permit

Date of issue of permit

Salt. 1. 19/9

.No.

1918

15 Self 1, 1919 Edward, J. Robban

(Month) (Day) (Year)

REGISTRAR

21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me Edward MR burns BEFORE the hurial or transit permit was issued .

MEDICAL CERTIFICATE OF DEATH

aug.

2%.

1919

....

16 DATE OF DEATH

(Montiy)

(Lay)

(Year)

I HEREBY CERTIFY, That I attended deceased from

aquil 15

, 19.19, to Cu

Na 29, 19 19

....

that I last saw how alive on

29, 1919.

and that death occurred, on the date stated above, at/

11.200 n. The CAUSE OF DEATH was as follows:

board room

Via @ Morrer Will.

to Sahurford.

and.

Peter MEGnauy.

Ireland!

Fore MiGnanly

roland:

Date ..

14 Fore Moric /H Growly

to cherry-ord.

1-6-'19. 150,000.

The Commonwealth of Massachusetts

232 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS

Ho Chelmsford

Middleed

St.,

Ward.

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

Official Unn. Clark position

ـبـ

REVISED UNITED STATES STANDART CERTIFIC

EXTR

FROM THE LA THE

ALTH O. MAS

GOVERNING THE

CERTIFI"

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 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 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 discase; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection necd 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,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Wcakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirthi 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.

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 arc 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 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.

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Deaths 1919, Part 23

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

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