USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1919 > Part 7
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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. - Reviscd Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of thesc 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 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 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.
18.7
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
1 PLACE OF DEATH
County
middlesex
State
masa
Registered No .. 22
City or Town
howell
No. 144 Wilder
(Place of residence) St ... Ward
2 FULL NAME.
Thurlow w.
(Itin the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State mass
(Usual place of abode)
City or Town, Chelmsford No.
St.
Length of residence in city or town where death occorred
Fears
mooths
days
How loog in U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year )de 17)913
7 AGE
Years
5
Months
DAYS
1 day. ........ hrs. .
If STILLBORN, coter that fact here
or ....... min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kiod of work ...
......
(h) Geoeral nature of iodostry, business, or establishment in which employed (or employer) ... (c) Name of employer
.. (duration))
Life
.... yrs.
.. mos ...
.... ds.
1
CONTRIBUTORY
(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 ?.
1.
What test confirmed diagnosis ?.
(Sigoed)
arthur O Scoloria
., M.D.
9-151919 (Address) Chelmsford mars
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
ideon Cemetery,
20 UNDERTAKER W.17. Saunders
DATE OF BURIAL mar. 16 10 19.
15
Fil ed mar. 17, 19 9/2016
Registrar of city or townothere death occorred
....
Filed
Caps. 8 1919 Edward ). albin
Registrar of city or town where deceased resided
16 DATE OF DEATH (month, day, and year) March 14, 2019.
17
I HEREBY CERTIFY, That I attended deceased from
19
19.
to
....
that I last saw h.
alive on
19
.........
and that death occurred, on the date stated above, at
If LESS thao
The CAUSE OF DEATH* was as follows:
* 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.) Congenital Heart Disease
F
9 BIRTHPLACE (city or town) Lo
(State or country)
mass
10 NAME OF FATHER John P.W.
PARENTS
11 BIRTHPLACE OF FATHER (city or town) howel. (State or country) maso
12 MAIDEN NAME OF MOTHER Julien Ro. Wallag
Lowell
13 BIRTHPLACE OF MOTHER (city or town). (State or country) mase!
14 Father
Informant (Address) E. Chilmelord man
of certificate.
MARGIN RESERVED FOR BINDING
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 statoment 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,
Lowell
(City or town) Registered No. 450
(Place of death)
......
(If death occurred in a hospital or institution, give its NAME instead of street and number)
25
MEDICAL CERTIFICATE OF DEATH
ADDRESS welf.
tion 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, Compos- itor, Architect, Locomotive engincer, Civil engineer, Stationary fircman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ctc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Carc should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Scrvant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (rctired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death .- Namc, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discasc. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, etc., of_
(namc origin; "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); Mcasles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (discasc causing death), 29 ds .; Broncho- pneumonia (sccondary), 10 ds. Never report mere symp- toins or terminal conditions, such as "Asthenia," "Ancmia" (mcrcly symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shock," "Uremia," "Weakness," ctc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. g., sepsis, tetanus) may be stated
sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or onc supposed to be duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
R 303. 6-'18. 50,000.
Form R-305
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, CHAPTERS 24 AND 29)
23
.Registered No.
(Place of residence)
City or Town ..
Lowell
No. St.
(If death occurred in a hospital or institution, give its NAME instead of street and number)
arthur Bishop (Leve
(If in the Army or Navy of the United States, give rank, organization, etc.)
St., 8 Ward.
no. Chelmsford Mais
(If non-resident give city or town and State)
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
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
march 27
(Day) /
(Month)
1919
(Year)
4 COLOR OR RACE
male /white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
C
6 DATE OF BIRTH
Jan, 21, 1902
(Month)
(Day )
(Year)
Years
17
Months
2.
Days
6
.
If LESS than I day ......... hrs. or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work
Secondhand
(c) Name of employer Silegiamille
9 BIRTHPLACE (City)
milford
(State or country) nº1+
10 NAME OF
Storage Levering
FATHER
11 BIRTHPLACE OF FATHER (City)
(State or country)
Canada
12 MAIDEN NAME
OF MOTHER
alberting Beaudette
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Canada
19 PLACE OF BURIAL, CREMATION/ OR REMOVAL
St.8
ford mars
9
DATE OF BURIAL
mar. 2919
(Month) (Day) (Year)
ADDRESS
20 UNDERTAKER a archambault howell
21 Burial permit issued by
Official position
22 Date of issue
.....
9-'18. 10,000.
2 FULL NAME 3 SEX 7 AGE PARENTS 14 15 should be carefully supplied. AGE should be stated EXACTLY. MEDICAL EXAMINERS should state CAUSE OF N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information See reverse side for extracts from the laws of the Commonwealth and instructions. DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. (b) General nature of industry, business, or establishment in which employed (or employer)
Informant
mother
(Address)
n. Chelmsford mars
Filed mar. 2494
Registrar of city or towy where death occurred
Filed
als. 8, 1919 (aduard ), Alfine
(Month) (Day) (Year)
Registrar of city or town where deceased resided
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 : haceration both thighs
mound fractureboth mora. traumatic computation left leg Run over fry railroad train accident (See reverse side fer additional space)
18 Where was injury sustained . Chelmsford if not at place of death?
(Signed).
This Is smith
......... N.D.
howell mass
(Address) ..
3 th Wist, middles
Medical Examiner
3-28 1919
(Month)
(Day)
( Year)
MARGIN RESERVED FOR BINDING
188
County ...... middlesex. State Trans ...... Registered No .. 5:39
((Place of death} A
St.,
Ward
(a) Residence. No. Princeton
(Usual place of abode)
If STILLBORN, enter that fact here
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 statement containing the facts required by law to be returned 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 hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot he obtained early enough for the purpose, or is insuffi- cient, 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 infor- mation 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 injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
COPIES OF RECORDS OF DEATHS OF NON-RESIDENT DECEDENTS
The clerk of each city and town shall forthwith make certi- fied copies of the records of all . . . deaths recorded during the previous month, if the . . deceased [was a resident] of any other city or town in this commonwealth or in any other state at the time of said . . . death, and transmit them to the clerk of the city or town of which such . deceased person [was] resident at the time of the said ... death ... and the clerk of a city or town in this commonwealth so receiving such certified copies, or certified copies of ... deaths, from the clerk of a city or town without the commonwealth, shall record the same. - Revised Laws, Chap. 29, Sec. 13, as amendde.' by Acts of 1910. Chap. 93, Sec. 3.
DESCRIPTION (for unknown person)
.... ....
...
....
.....
....... ..... .... ...
r
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Malik
State ..
mass
Registered No. 24
Township
City
No ..
St.,. ... Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Hattie Joanna Vickery
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
Westend Road.
St.,.
.. Ward.
(Usual place of abode)
Length of residence in city nr town where death nccnrred
years
months
days.
How Inng in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Temale
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) Married
5a If married, widowed, or divorced HUSBAND of (or) WIFE of Walter &. Vickery
6 DATE OF BIRTH (month, day, and year) May 15-1869
7 AGE
Years
49
10
Days
23
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, nr establishment in which employed (nr employer) (c) Name of employer
.... (SECONDARY) 11 Surnal Mian - ds.
... (duration)
............... yrs ....
.mos .....
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?...
........
ma Date of.
Was there an autopsy ?.
What test confirmed diagnosis ?..
(Signed)
M.D.
4.9. 1919 (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.)
14
Informant
Waller E. Vickery
(Address)
15
File apr. 9., 199 Edward). Robbins
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
apr, 7, 19/9.
17
I HEREBY CERTIFY, That I attended deceased from
March 1
1919, to.
apr, 7
,1919.
that I last saw h alive on
...
apr. 5
, 1919
and that death occurred, on the date stated above, at
3:30 p .. m.
The CAUSE OF DEATH* was as follows :
acute Bronchitis
....
.. (duration)
.yrs ....
.. mos ..... ds.
CONTRIBUTORY
Mercadito
9 BIRTHPLACE (city or town) ......
Henniker
(State or country) N.++
10 NAME OF FATHER about @ clark
PARENTS
11 BIRTHPLACE OF FATHER (city or town). (State or country) N. H
Hemiker
....
12 MAIDEN NAME OF MOTHER Hattie J. Clark
13 BIRTHPLACE OF MOTHER (city or town) Hanniher (State or country) Natt
PLACE OF BURIAL, CREMATION, OR) REMOVAL DATE OF BURIAL Line Badge- Clicknefend Aby. 9 19/9
20 UNDERTAKER
ADDRESS
Walter Perham Chelmsford.
MARGIN RESERVED FOR BINDING
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
189 Chelinford Mais (City or town)
.. or
.or Village ..
Centro
(If non-resident give city or town and State)
Months
.................
5 wales.
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupativii. - Precise suaichend of occupa- tion 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, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, _Farm laborer, Laborer -Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- catcd 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 timc and causation), using always the same accepted term for the same discasc. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, etc., of.
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discasc; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal. conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapsc," "Coma," "Convulsions,"' "Debility" ("Con- genital," "Senile,"_etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under thic head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Casas for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
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