USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 26
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30
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, ete. 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,""Ileart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Wcakness," etc., when a definite disease can be ascertained 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- mittee on Nomenclature of the American Medical Association.)
Bronehopneumonia: 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, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riago, 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 deccased, his supposed age, the disease of which he died [defined so that it can be classificd 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 faets 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 suficient 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 sueh 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 pcr- 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 dicd, his name and residence, if known, otherwise a description of such person as full as may he, 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 eauscd 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 oceupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
:
FORM R-303
The Commomuralth of Massachusetts
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
(ASSUED UNDER THE PROVISIONS OF REVISED LAWS, CHAPTER 24)
Mais
State
Bill RR
St.,
Ward
Marconi Ra(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.)
St.,
.Ward,
(If non-resident give eity or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED, WIDOWED OR
DIVORCED (write the word)
Angle
6 DATE OF BIRTH
Jan 29. 1905
(Day)
Year)
If LESS than
1 day ....... brs.
or ....... min.
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 : Comminated Traceur fity Still,
Compound Fracture of Ley Fracture of ary and Rito accidentally struck Of railroad trans at crowding
(See reverse side for description for unknown person) .......***
18 Where was injury sustained if not at place of death?
(Signed)
Thomas
M.D.
(Address)
107 Werewack By La
Lowel
5th Dret huddlesex Co.
Medical Examiner for ..
Date ..
(Month) (Day) (Year) /
19 PLACE OF BURIAL, CREMATION, or REMOVAL
DATE OF BURIAL ItJatuels Lowell Sept 211 (Cemetery)
(City or town)
(Month) (Day) (Year)
20 UNDERTAKER
ADDRESS
21 Burial
issued by.
Edward J. Rotom Official position .....
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Month)
Sept
(Day)
18
1919
"Year)
MARGIN RESERVED FOR BINDING
1-18-'19. 25,000.
1 PLACE OF DEATH
County ..
City or Town
Chelmsford
2 FULL NAME
(Usual place of abode)
Length of residence in city or town where death occurred
years
3 SEX
4 COLOR OR RACE
imale while
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
7 AGE
U Year's
Months
/ 9Days
If STILLBORN, epter that fact here
If STILLBORN, 'state period of nterogestation.
.. mooths
8 OCCUPATION OF DECEASED
(n) Trade, profession, or
particular kind of work.
(b)> General nature of industry,
9 BIRTHPLACE (City) Louer
(State or country)
mass
FATHER
11 BIRTHPLACE OF
FATHER
(City )
(State or country)
Sisland,
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF
PARENTS
MOTHER (GIty) .....
(State or country),
Informant
(Address)
File
should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms,
N. R. - 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) pour factor
(c) Name of employer Jaúdel Textile Co.
10 NAME OF
Gerard Jour
Elizabet Butter
Quistand 14 Eles abit Sans bythe
15 Scouts Stelt
15 Sett, 20, 1919 Edward J. Robban ( Month (Day) (Year) REGISTRAR/
239
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
Registered No.
74
Viaco
(a) Residence.
No.
0 15 Brooks
months
days
How long in U. S., if of foreign birth?
years
Term Cluck 22 Date of Seft, 2019/9 Permit No
L
....
19:01
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 deatlı. . . - 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 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 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 clectrical 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 wound 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 sustainéd 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.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
FORM R-301
MARGIN RESERVED FOR BINDING
1 PLACE OF DEATH County .. Middlesex ( Usual place of abode) Length of residence ia city or town where death occurred 3 SEX 4 COLOR OR RACE Fem. White 5a If married, widowed, or divorced HUSBAND of (or) WIFE of - 6 DATE OF BIRTH ( Month) 8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work ... (b) Generai nature of industry, business, or establishment in which employed ( or employer). (c) Name of employer 10 NAME OF FATHER Ira Parks (State or country) 13 BIRTHPLACE OF PARENTS MOTHER (City). 14 Informant. ZIra Parks should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH 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 ( State or country) Mass.
The Commomuralth of Massachusetts STANDARD CERTIFICATE OF DEATH
240 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
Registered No
75
St., .Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Still Born (Parks)
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
Middlesex St.,
St., ..
.Ward.
(If non-resident give city or town and State)
months
days
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY, That I attended deceased from .
19.
...... , to.
, 19
that I last saw h
...
alive on
.,
19
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH was as follows:
.(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? Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed).
Tutulan.
M.D.
(Address).
Vyro elulmalard.
Date S.l.x
95
(Month)
Y Bay) ... , ( Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL St. Joseph, E. Chelmsford (Cemetery) (City or town)
DATE OF BURIAL
9/27
19 19
20 UNDERTAKER A. Archambault
ADDRESS
Lowell.
Offi position ...
a Down Clock
Date of issne of permite Sett 26,19kg ×
Permit
1-6-'19. 150,000,
Sept. 25
1919
(Day)
(Year)
7 AGE - Years - Months - Days
If LESS than
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation.
..... mos.
1 day ......... hrs.
or ........ min.
Still Bou.
9 BIRTHPLACE (City)
No. Chelmsford
11 BIRTHPLACE OF
FATHER (City ).
Nova Scotia
12 MAIDEN NAME OF MOTHER Grace Gervais
Amesbury, (State or country) Mass.
(Address) No. Chelmsford, Mass.
15
Soft, 26,1919 Edward J. Robbing
(Month) (Day) (Year)
REGISTRAR
21 ! HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the hurial or transit permit was issued ... f. Edward J. Robban
State
Mass.
City or Town ....
North Chelmsford
No.
Middlesex
.........
days.
How long in U. S., if of foreign birth ?
years
years
months
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
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 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 laborcr; 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 DEATII, 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 DEATII (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 (sccondary 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," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," ete.
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], whero 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 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,
1 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- 1 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 cxamination 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 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, tho 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
241
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County ......... Middlesex
State ...
Mass.
Registered No ..
76
City or Town ... No, Chlemsford
No.
Middlesex
St.
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.