USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 30
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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, 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, fur nish 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. 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 deccased died, his name and residence, if known, otherwise a description of such person as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are supposed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
-
FORM R-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)
County
midilieux
State.
mais
Registered No.
85
City or Town
Chelmsford
No.
Pratos Ploac Complinevlast
.. 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.)
St.,
Ward.
( If non-resident give city or town and State)
Lengtb of residence in city or town where death occurred
years
n'onths
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
(found dead)
(Month)
(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 ?! Chronic Heart Dimare with secondary Arthritis found dead.
2 Found dead letting en drie en vous; lived aires.
(See reverse side for description for unknown person)
18 Where was injury sustained
if not at place of death ?.
V howar
(Signed)
M.D.
(Address).
107 himun arch. Lowell
5out, Lindales , 60
Medical Examiner for.
Date ..
(Month)
(Day)
(Year)
14
Informa
Harry Q. Miller
(Address)
Haverhill mann
15 File a Oct. 28, 1919 Edward &. Robbins (Month) (Day) (Year) REGISTRAR
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
21 Burial permit Edward & Robbins issued by Town Clock
Official position
22 Date of Oct. 28,1919. issue
Permit No
2 FULL NAME 3 SEX Male (b) General nature of industry, (State or country) PARENTS 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)
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED OR
D:VORCED (write the word)
mider
5a If married, widowed, or divorced
HUSBAND of
, (or) WIFE of
6 DATE OF BIRTH
let
(Month)
13
1835
(Day)
(Year)
7 AGE 84 Years 0 Months 12 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. farmer
9 BIRTHPLACE (City).
Concord R.H.
10 NAME OF
FATHER
John Miller
11 BIRTHPLACE OF
FATHER (City ) ...
Brunswick
(State or country)
moine
12 MAIDEN NAME
OF MOTHER Sallie Emery
13 BIRTHPLACE OF
MOTHER (City)
Each Concord
(State or country)
21.14.
19 PLACE OF BURIAL, CREMATION, or REMOVAL
Harr Pond Ceny So Chelinford
(Cemetery)
(City or town)
DATE OF BURIAL Oct 28 1919 (Month) (Day) (Year)
1-18-'19. 25,000.
should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms, N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information (c) Name of employer
(a) Residence.
(Usual place of abode)
John R Willer
Novoton Road, Cujo Piccola
Det.
27
1919
.....
MARGIN RESERVED FOR BINDING
250
EXTRACTS
FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a stand- ard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 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 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 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 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.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be 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,
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
....... .............
(City or town)
1 PLACE OF DEATH
County ..
Medix
State
Mass
Registered No. 86
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)
2 FULL NAME
.......
(Usual place of abode)
Length of residence io city or town where death occurred
years
mooths
days.
How long in U. S., if of foreigo birth ?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced HUSBAND of (01) WIFE of
6 DATE OF BIRTH (month, day, and year)
Oct 301919
7 AGE 0 Years
O Months
O Days
If LESS than 1 day ......... hrs. or ....... min.
8 OCCUPATION OF DECEASED
(a) Trade, professioo, or
particular kind of work.
-
(b) General nature of iodustry, business, or establishment io wbich employed (or employer). (c) Name of employer
9 BIRTHPLACE (city or town)
Chelmsford
(State or country)
10 NAME OF FATHER George H. Morton
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country) England
12 MAIDEN NAME OF MOTHER Rose alexander
13 BIRTHPLACE OF MOTHER (city or town).
Pelham
(State or country) n.H.
14
Informant
8H martin
(Address)
15
Filed. Oct. 3%, 1919 /oderand J, Rol Fing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and ycar)
Oct. 30,
19 / 9.
17
I HEREBY CERTIFY, That I attended deceased from
lect. 30
19.19, to.
6ex. 30
, 1919 .
.
that I last saw him alive on
Oct. 30
19/19.
and that death occurred, on the date stated above, at
.............
m.
The CAUSE OF DEATH* was as follows:
Premature buch
...... .....
(duration)
mos .... .. ds.
CONTRIBUTORY
(SECONDARY)
... (duration)
... yrs ................. mos ................ ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death?
200. Date of.
Was there an autopsy ?.
no.
What test confirmed diagnosis ?...
(Sigoed).
Atom Y. Scobanca
.,
M.D.
10-3019/9 (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. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Pine Ridge Con, Cheliste
DATE OF BURIAL
Oct 31 1919
20 UNDERTAKER
ADDRESS
Chela
MARGIN RESERVED FOR BINDING
of certificate.
Stillborn) Morton
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
Chalets
St.,
......... .Ward.
...... ......
(If non-resident give city or town and State)
251
.. yrs .....
1/2 hora
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to each and every person, irrespective of age. For many oeeupations 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 fircman, ete. 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 ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specifieation, as Day laborer, Farm laborer, Laborer - Coal minc, etc. Women at home, who are engaged in the duties of the household only (not paid Housekcepers 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- eifieally the oceupations of persons engaged in domestie serviee for wages, as Servant, Cook, Housemaid, etc. If the oeeupation has been changed or given up on aceount of the DISEASE CAUSING DEATH, state oceupation at beginning of illness. If retired from business, that faet may be indi- eated 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 affeetion with respect to time and eausation), using always the same aeeepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic eerebrospinal 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, ete., Carcinoma, Sarcoma, ete., of _.
(name origin; "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (secondary or inter- current) affeetion need not be stated unless important. Example: Measles (disease eausing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con-
genital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," ."' "Old age,' e." "Shoek," "Uremia," "Weakness," ete., when a definite disease ean be ascertained as the eause. Always qualify all diseases resulting from ehild- birth or misearriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State eause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably sueh, if impossible to de- termine definitely. ~ 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 fraeture of skull, and consequences (e. g., sepsis, tetanus) may be stated
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 eaused by violenee, 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, ete.
4. Deaths under eireumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS
BY
PHYSICIAN.
T 15. 10-'18. 5,000.
adama South G. adama amir 6 alcom Donald adams Ruth nettie ayotte Arthur & 1
38 Bistar Herbut R. 49 Bliss Pliney 6. 84 Blodgett Fredy. 92 Buntel Thomas Byam James S.
Bengston Mathilda
Belair marie L. 53
Bean Jennie S. 57 Batchelder ann M. 78 81
Burpee Orinda
Suntel Charles D. 82
Bradley Isaac 2. 87
Blaisdell Clara of. 91
Boies Abbie J. 93
Byam Ida E.
101
Butter Clara S. 108
Bartlett Joel Adams 109 Beau Pred E. 122 Baies Andrew 2. 126
Bullard Achsch D. 139
Bridgeford Educa L 141 U
Brandette Elizabeth 159 V W
Bradley Ellen G. 167
1 Bakker Jellem .. 11 24. C 27 D 30 E 51 33 F 44 G H I J K
A
B
L M N 0 P Q R S T
Crawford Marie P. B. Colburn alfred S. Car mary It.
Capelle Cyprus S. 55
Guyan Hannah 6%:
Cummings Mary a. 80
Gudworth Cara R. 106
black Ement E, 130 Daigle mary
Grease Parathy is,
Clarke
Charles Asa G.
Gabry Marcha
Champagne Exchariste 144
Cari Elizabeth A, 166
Junigan mary 11.14
Dulce Henry +. 18
4 16 26 Dronne maria Q.B. 23 Jugar Octavie 31
Davie annie & 3] 59
Dollard Elizabeth Ducharme 70 79
134 Drewatt Louisa 88
135 Dutton Ruth B 104
145 158
Daran Ellen 114
Burgin seo. A. 115 Dum James D, 147 Dickinson Ernest C, 150
Ono Henri .. 6.3 Emerson Walter B. 76
Earle Charles 85 Emerson Hurry A. .. 10.3
Frisette Marie 35 Flynn Edward 48 Fick Lottie 6? 75 Flynn Margarit m, 94 E
Flores
118 F
- G
H
:
I J K L M N 0
P Q R S
T
U V
7 Harrington anna 36:
113 Haley Bridget 42
12/ Harmon Les. a.
66 Howard Amaca 98
144
Goodwin Susan &. Green Rachel F. Gervais Saurial Sibrou Melitable S. 129 Gilman Frank Grant Archibald 153
bage tiram le. 157
Hamlin Mary B. 123 Harrison Lucro 136 Hubbard Emma 8, 148 Henderson Carline . 152 Huntoon Benice E. 156 Hunter 168
Sauce John for Ineson Verey cf.
25 99
Johnson Nina a. Sabaton Jameson B. 68
Johnson Addic Q. 146
I J K L M N D P
Q R S T U V W
Kostechko alexander Kostechka
83
124
i
1
Lakin 54 Lowe Fabriek F1.02 Lathrop Heury Or, 105 Lakin 133 Le Marinet Scher Ir . 142
Michalowski Josephine Mcmahon michael mcgrath Own F. meagher mary a. malone John J. meckin Martha McQuade 90
58
112
Maquell Jahren. 116 Minutly alice R. 132 Mac Elroy Mary A, 137 Mc Caffiy Solic 9, 149 Macrae Jeunic A. 155 Merrill Elizabeth 8. 160
2 Farten Jessie B. 32
15 Nelson agreed 4.3
20 Nilsson Diza 8. 50 40 Mizeiela Joseph 74
45 Melon Artenues M. 119
M N 0 P Q R S T U V W
Pickhuf Sumed. 22 29
Pratt mary Parkhurst Victor 2. 39
Poisson Edward 65
Peterson 67 Parker Edición I. 96
Preseatt Sarah A. 100 Parkhet Victo 3. 138
Germinan Phala 1.54
Page Motel E. 161
Quatters Millicent 16V
Reid James 9 Ryan mary 41
Triney annie to 73
Reed Otis A. 127
Reedy Reich I. 131
Ready Patrick & 151
Q
T
U V
W
Small D. Frank
Stone Joseph a. fr.
Steams James IT.
Sargent Sophia R
Silva agnes
Stone mary Ellen
21
Smalley Ruth &
28
Stevine Charlotte a.
56
Smith Robert S.
62
Smith George H. 77
Spalding Minot &. 86
Saunders Elizabeth S. 89
Scollow Quen A. 95
Stearns Sarah E.
107
Swenson august L. 110 Silva Arma 120
Sivous Many 125
St Ouge Aque. 128
Steven Sidney n. 140 Sargent South I. 143
165
5
Osirimbas antonior 34
6
Consignant Lillian 64
8 Nrubry James F. 69 Tufts Samuel A. 97 10 Sitterington Elig auch 163 17
71
Verge Hubert 2
:
1
U V W
Hardwell Neken H. B. 12
Whidden albert S.
13
Sikander Sustal 19
Wheeler nettie F. 47
Aright Helen P. 52
Wrigley John B. S. 60
Windden George W. 72
Hardwell Lucy A. 111
Henriauch Schau A.
117
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