USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 15
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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 diseasc. Examples: Cere- brospinal fever (the only definito synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobor pneumonia; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, men- inges, peritoneum, etc., Corcinoma, Sarcoma, etc., of ... . (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Meosles; 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," etc.), "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 deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, 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 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 are supposed to have come to their death by violence. - Revised Laws, 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.
-.....
FORM R-301
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
State Mars
Registered No.
39
St .. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Elisa O. Nilsson
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No ..
( Usual place of abode)
Ruale Mill Rd.
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
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word)
5a If married. widowed, or divorced HUSBAND Of (or) WIFE of
Sono nilsson Sapt (Month)
241) (Day)
1866 ( Year)
If LESS than 1 day, ........ brs. or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or at home
9 BIRTHPLACE (City) (State or country)
10 NAME OF
FATHER
Henry Judge
11 BIRTHPLACE OF
FATHER (City)
(State or country)
England
12 MAIDEN NAME
OF MOTHER
Elija Bygrace
13 BIRTHPLACE OF MOTHER (City) (State or country) England
MEDICAL CERTIFICATE OF DEATH
July
24
1920
(Year)
(Day)
17
HEREBY CERTIFY, ThatI attended deceased from
July 24
19 20
to
that I last saw h en alive on
July 24
19 20.
and that death occurred, on the date stated above, at
$2000 m.
The CAUSE OF DEATH was as follows: Angina Pectoris
5 hours
(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 ? ILA Date of
Was there an autopsy ?
no.
What test confirmed diagnosis ?. (Signed). Aula , Scotoria
M.D.
(Address).
Clubuneford, Thors.
26
1920.
Date
Monthy
(Day)
( Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Pine Ridge
Chantal
(Cemetery)
(City outown)
DATE OF BURIAL July 271920
15 July 27,1920 Edward, Robbing
Filed (Month) (Day) (Year)
REGISTRAR
20 UNDERTAKER
Walter Perham
ADDRESS Chelmsford
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued Edward , Robbins Officia . position ..
Com Click
Date of issue of permit
Permit
1-6-'19. 150,000.
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
3 SEX 6 DATE OF BIRTH particular kind of work (c) Name of employer PARENTS 14 (Address) 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 (b) General nature ofindustry, business, or establishment in which employed ( or employer).
MARGIN RESERVED FOR BINDING
N. B. - WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information
50 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
Index
City or Town
Chelmsford
No.
.St.
.Ward.
( If non-resident give city or town and State)
16 DATE OF DEATH ..
(Month)
, 19 20.
7 AGE
5.3 Years
10
Months - Days
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation
.. mos.
Informant Four children
Chelmsford
No
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. Butin many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer -- Coal mine, etc. Women at home, who are engaged in the duties of the house- hold only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING 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 ("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 (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,""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 deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 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 thercof 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 tho 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 thercafterfurnish 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 eity registrar in the place where the deceased died, his name and residence, if known, otherwise a description of such person as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are supposed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
-
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Form R-302
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
(City or town)
1 PLACE OF DEATH
County
Middlesex
State
mars
Registered No.
40
City or Tow
howell
(If death occurred in p hospital or institution, give its NAME instead of street and number)
2 FULL NAME
mass,
City or Town
(Ifjolthe Army or Navy of the United States, give rank, organization, etc.)
testate faire rank
helmekord No.
St.
(a) Residence. Statė
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
5 days
How long in U. S., if of foreign birth?
39
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
( or ) WIFE
alexandera.
6 DATE OF BIRTH (month, day, and yeap Fel, 181873
7 AGE
Years
Months
Days
47
4
29
If LESS than
1 day, ........ brs.
or ........ min.
If STILLBORN, enter that fact bere
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
Of Home
(b) General nature of industry, business, or establishment in which employed (or employer). (c) Name of employer
9 BIRTHPLACE (city or towm)
(State or country) ( Sweden
10 NAME OF FATHER harson
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country) Sweden
12 MAIDEN NAME OF MOTHER amofily learned
13 BIRTHPLACE OF MOTHER(city or town) (State or country)
14 dualo
Informant ( Address) Chelmotor mars
15
File
Register of city of town where death occurred Filed 1920 Celwand ), Rolling
Registrar of city or town where deceased resided
16 DATE OF DEATH (month, day, and year) July 17 1920
17 HEREBY CERTIFY, That I attended deceased from July 12 19 28. to
20
that I last saw her alive on
/12
19
20
3.45.
m.
and that death occurred, on the date stated above, at 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.) Surgical Shock
.... (duration).
yrs ..........
.. mos.
......
de.
CONTRIBUTORY
Fibroid Tumor of
(SECONDARY)
vocerue (duration)
yrs.
............. mos.
. ds.
18 Where was disease contracted
if not at place of death ?
of rely /2,1920
Did an operation precede death ?_
Was there an autopsy?
What test confirmed diagnosis?
(Signed)
the Cage
M.D.
7-17 192 (Address)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Chelmsford mass.
DATE OF BURIAL mely 1920 20
20 UNDERTAKER ADDRESS Wir.H. Saunders Lowell
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,
of certificate.
bely 20, 19200 Flumay
51
well
Registered No.
(Place of death)
(Place of residence)
Ward
Mathilda Bengtzon
MEDICAL CERTIFICATE OF DEATH
Rs.
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 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- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: 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- toneum, 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 .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toins or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," ""Convulsions," "Debility"' ("Con- genital," "Senile," etc.),
"Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shoek,"" "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," ete. 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 suchi, 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 the 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.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due 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-301
The Commonwealth of Massachusetts
52
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County ..
Middleccf Crentes
City of Town Lowell
State No. Cont
Registered No. LLI
St ..
Ward
((If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Helen P. Wright
(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)
months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female While. Single.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
( Month)
(Day)
(Year)
7 AGE
Years
Months
Days
If LESS thao
If STILLBORN, ester that fact here
If STILLBORN, state period of oterogestatina
mos.
1 day, ........ brs.
pr ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work. (b) Geoerai oature nf industry, business, or establishment in which employed ( or employer)
(c) Name of employer
CONTRIBUTORY
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