USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 10
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County
mans
Registered No.
City or Town howell
(If death occurred in a hospital or institution, give its NAME instead of strcet and number)
2 FULL NAME anna 2 Harrington
(a) Residence. No. (Usual placc 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
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
W.
DIVORCED (write the word)
married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
John
6 DATE OF BIRTH
(Month)
(Day)
7 AGE
36
Years
Months
Days
If LESS than 1 day. ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work Operative
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of emplo: . I. Cartridge Co.
9 BIRTHPLACE (City) (State or country) Ireland
10 NAME OF
FATHER
John harry
PARENTS
11 BIRTHPLACE OF FATHER (Qty)
(State or country)
Irelandi
12 MAIDEN NAME OF MOTHER
mary sullivan Date
13 BIRTHPLACE OF MOTHER (City) (State or country)
Ireland
14
Informant
(Address)
Chelmsford Mars.
15
Filed
May 18,1920 Stephen Flynn (P. Registrar of city or town where death occurred June 7, 1920 Edward J. Rotting
Filed (Both) (Day) (Year) Registrar of ciff or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Month)
may 5
(Day)
1920 ( Year)
17 I HEREBY CERTIFY that I have investigated the death of the person above-named andthat the CAUSE AND MANNER thereof are as follows : accident
(Year) Fractureof base ofskull received by being knocked down by @ motorcycle
(See reverse side for additional space)
18 Where was injury sustained 1
if not at place of death?
(Signed)
Marcha 1 De alling
M.D.
(Address)
Caso, Medical Examiner for
5thwish middlesex
May
(Month)
(Day)
12 920 ( Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL
St. Patrick howell
18,1920
(Month) (Day) (Year)
20 UNDERTAKER O'Connell+ day
ADDRESS howell
21 Burial permit issued by
Official position
22 Date of issue
9-'1S. 10,000.
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.
36
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
23
Registered No.
Forham( Ho apital)
(Place of d) w noplace of residence)
Ward
Cheli if rank, of
ford Mais
(If non-resident give city or town and State)
St.,
Ward.
MARGIN RESERVED FOR BINDING
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 be 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 certifics to the cause of death shall thercafter 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 dicd, 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- poscd 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 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 discase unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths 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 . . . dcath, and transmit them to the clerk of the city or town of which such . . . dcceascd person [was] resident at the time of thesaid ... 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 amended? by Acts of 1910. Chap. 93, Sec. 3.
DESCRIPTION (for unknown person).
FORM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
huddlesex
State mais
City or Town)/ 2607673
City or Town
No thulinfard
No.
St .. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
amie IDavie
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
(Usual place of abode)
North Chelmsford st
.Ward.
(If non-resident give city or town and State)
Length of residence in city or towo where death occorred 2 2
years
months
days.
How long io U. S., if of foreign hirth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
0 .
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
manud
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
William In Dance
6 DATE OF BIRTH
1029-1852
( Month)
(Day)
(Year)
7 AGE
Years 68
Months
2
Days
If LESS than 1 day, ........ hrs. or ........ min.
If STILLBORN, eoter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
(h) Name of employer
9 BIRTHPLACE (City)
.....
Scotland
(State or country)
10 NAME OF
FATHER
Walter me Knowlton
PARENTS
11 BIRTHPLACE OF
FATHER (City)
Scotland
(State or country)
12 MAIDEN NAME
OF MOTHER
Jennie Black
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Scotland
14 Um In. Davie
Informant .... (Address) No Chulampard
15 may 15, 1920 Edward & Rotting Filed (Month) Day) (Year) REGISTRAR
20 UNDERTAKER .Hepburn Blake
ADDRESS Lowell -
Permit
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued award & Robbins Official . position
bon Click
Date of issoe of permit
Away 15- 1920 No.
instructions and extracts from the laws on back of certificate.
11-13-'19. 50,000.
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
N. B. - WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
The Commonwealth of Massachusetts
37.
(Sigoed).
Frank & Philips
M.D.
(Address).
Dorthe Chelmsford near
Date
may
15
1920
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Avenida No Checksand
(Cemetery)
(City or town)
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 ?
(duration)
.yrs ..............
mos ...
ds,
CONTRIBUTORY
(SECONDARY)
(duration)
(Year)
17 I HEREBY CERTIFY, That I attended deceased from May 15 1920 May 15 1920 to ...
that I last saw h.L.L ..... alive on
13-
19.20,
and that death occurred, on the date stated above, at
200
.. m.
The CAUSE OF DEATH was es follows : apoplexy
MARGIN RESERVED FOR BINDING
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
may 15-1920
(Day)
(Month)
Registered No:
DATE OF BURIAL Jay 17 1920
What test confirmed diagnosis ?.
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., Former or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stationory 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 Doy laborer, Farm loborer, 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 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 "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pncumonia," unqualified, is indefinite); Tuberculosis of lungs, men- inges, peritoneum, etc., Carcinoma, Sarcoma, etc., of .. . (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not 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," ete.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," · etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
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 deccased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contractcd, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Lows, Chop. 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 licu 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 certifics 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 are supposed to have come to their death by violence. - Revised Lows, Chop. 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.
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, i N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of Information should be of certificate.
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
1 PLACE OF DEATH
4
County
middleser
State.
mans.
.Registered No.
(Place of residence)
. Ward
2 FULL NAME
mars.
City or Towk wchelmsford No.
Worthen
St.
Length of resideoce io city or towo where death occurred
years
months
days
How long io U. S, if of foreigo birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
m.
4 COLOR OR RACE
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 ready for. 30.1920
7 AGE
Years
Months
Days
9
If LESS thao
1 day, ........ brs.
or ....... mio.
If STILLBORN, enter that fact bere
8 OCCUPATION OF DECEASED (a) Trade, profession, or .. particular kind of work
(b) General nature of industry, business, or establishment io wbich employed (or employer) (c) Name of employer
Lowell
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?
arthur 9 Icoloria
(Sigoed)
M.D.
14
Informant (Address)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL there helmofor Marsi Ping Midge Chelmsford, May 10 1920.
15 Filed May 11, 1920. Stephen Flynn (P.)
Registrar of city or towo where death occorred
File
Jame 7, 2020 Edward . Rothe
Registrar of city or towo where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) May 9
1920
17
19
I HEREBY CERTIFY, That I attended deceased from
april 20
20
May 9
19
20
to
19 19 20.
that I last saw HUMAN -live on
and that death occurred, on the date stated above, at m. 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.) marasmus
L
9 BIRTHPLACE (city or town) (State or country) mass.
10 NAME OF, FATHE william E
PARENTS
11 BIRTHPLACE OF FATHER (city or town Chelmsford
(State or country)
mais!
12 MAIDEN NAME OF MOTHER the Scale
Chelmsford
13 BIRTHPLACE OF MOTHER (city or towalk (State or country) mais
57-9192 (Address)
20 UNDERTAKER
ADDRESS
Walter Perham Chelmsford
Registered No.
782 (Place of death)
City OF Town Lowell.
Nav
Cheney allard Horst.
(If death occurred in a hospital or institution, give its NAME instead of : treet and number)
amore Everett adam
(in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. Sta
(Usual place of abode)
MARGIN RESERVED FOR BINDING
38
Lowell. ( City of fo
.(duration).
9
.. ds.
......... yrs.
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 cach 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, Architeet, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is nceessary 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 sceond 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 spc- cifieally the occupations of persons engaged in domestic serviec 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 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 affcetion with respeet to time and causation), using always the same aeecpted term for the same disease. 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- ficd, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, cte., Carcinoma, Sarcoma, etc., of_
(name origin; "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie valvular heart discase; Chronic interstitial nephritis, cte. The contributory (secondary or inter- current) affeetion need not be stated unless important. Example: Measles (disease eausing death), 29 Gs .; 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- inus," "Old age," "Shoek," "Uremia," "Weakness," ete., when a definite discase can be aseertained as the eausc. Always qualify all discases resulting from child- 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 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 fraeture of skull, and consequences (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." (ReeolLe er.dations on statement of cause of death approved by committee on Nomenclature of the American Medical Assur tion.)
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 Medieal Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
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