USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 27
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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, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the ohservance 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 disahled 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 hy the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following ahortion, 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
N. B. - WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information instructions and extracts from the laws on back of certificate. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
The Commomuralth of Massachusetts
81
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
Midey
State
mars.
Registered No. 70
St. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Orinda Burpee
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
Littleton Rd
St.
Ward.
(if non-resident give eity or town and State)
Leogth of resideoce in city or lowo where death occurred
10
years
moothis
days.
How long io U. S., if of foreigo hirth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
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
april
( Month)
29 1843
(Day)
(Year)
7 AGE
77
Ycars
7
Months
Days
If LESS thao
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work at home
(b) General nature ofiodustry,
business, or establishment io
which employed ( or employer)
(c) Name of employer
9 BIRTHPLACE (City)
Sandwich Mars
(State or country)
10 NAME OF
FATHER
Hiram Burpes
PARENTS
11 BIRTHPLACE OF
FATHER (City).
Grantham n.H.
(State or country)
What test confirmed diagnosi?
(Signed)
Antw Y. Scolonia
1
M.D.
13 BIRTHPLACE OF
MOTHER (City)
Rumney
(State or country)
n.H
-Date
Dic.
(Month)
( Day)
14
Informant.
Agora Burpee (Sister)
(Address )
Chalmers
15
DEC. 9, 1920 Edward J. Rotfring
Filed
(Month) (Day) (Year)
REGISTRAR
20 UNDERTAKER
Natur Pestana
ADDRESS
Chelmsford.
21 I HEREBY CERTIFY that a satisfactory stao- dard certificate of death was filed with me BEFORE the burial or transit permit was issued Edward &
Official Vorn Clack
position ..
Date of issne of permit Dec. 9, 1420 No
Permit
1-6-'19. 150,000.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
Dec
9
1920
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
nor.19
19.20
to
Dec.
6
that I last saw her alive on
DEc. 5, 1920,
and that death occurred, on the date stated above, at
5 a. m.
The CAUSE OF DEATH was as follows :
Left Hemiplegia-
(duration)
yrs ..
mos ...
18
.ds.
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 ?
no.
12 MAIDEN NAME
OF MOTHER
achsal Hoster
(Address).
Chelandlord, mass
7
1920.
... ...
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Mit. Hope
Sandwich Mars.
(Cemetofy)
(City or town)
DATE OF BURIAL
Dec 9 1920
, 19 20.
If STILLBORN, enter that fact here
If STILLBORN, state period of oterogestation
... mos.
MARGIN RESERVED FOR BINDING
STANDARD CERTIFICATE OF DEATH
City or Town
Chelmsford
No.
( Usual place of abode)
5
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, Civilengineer, 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 bo 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," "Dcaler," 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 DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cere- brospinal fever (the only definite synonym is "Epidemic cercbrospinal 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,""Senilc," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can be ascertaincd 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, furnislı for registration a standard certificate of death, stating to the best of his knowledge and belicf 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. 822.
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 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, 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 persens to whom they have given bedside care during a last illness from disease unrelated to any ferm 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 ferm 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 diseaso, and those of persons found dead.
FORM R-301
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information instructions and extracts from the laws on back of certificate. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Imddlieu
State
mass
Registered No.
St.,
Ward
(If death Oreurred m a hospital or institution, give its NAME instead of street and number)
Charles D. Buntel
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
No Chelucund
St.,
Ward.
( Usual place of abode)
Length of residence ia city or towo where death occorred
3
years
months
days.
How long io U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
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~
Jan 8-1860
( Month)
(Day)
(Year)
7 AGE
Years
Months
Days
If LESS thao
60
I day, ........ hrs. or ........ min.
If STILLBORN, enter that fact here
3
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work. (b) Name of employer
(Harmer
9 BIRTHPLACE (City)
(State or country)
England
10 NAME OF
FATHER
Char Buntel
PARENTS
11 BIRTHPLACE OF
FATHER (City)
(State or country)
(France
12 MAIDEN NAME
OF MOTHER
madaluz Govie
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Grance
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
Dec.
12
1920.
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
20028
19.20
Dec. 11
19
20
that I last saw h ILLA alive on
Dec. 11
19 ... 2 ... Q
and that death occurred, on the date stated above, at
1
p.m.
The CAUSE OF DEATH was as follows :
chromes nephritis
,
(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?
no
Was there an autopsy ?
What test confirmed diagnosis ?
Moral
(Sigoed).
Frederick D. LambertM.D.
Date
(Address).
T ingsenough mese.
DeR.
12, 1920
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
(Leverede Nochdunkel
(Cemetery)
(City or towna
DATE OF BURIAL Orc/o To 20
20 UNDERTAKER W.Herburn Blake Lowell ADDRESS
Permit
11-13-'19. 50,000.
21 I HEREBY CERTIFY that a satisfactory stao- dard certificate of death was filed with me BEFORE the burial or transit permit was issoed Edward, I, Rotting
OfficialConcluk
position
Date of
issne
of permit.
DEC. 13, 1720 No.
MARGIN RESERVED FOR BINDING
The Commonwealth of Massachusetts
82
(City or Towns] 071
City or Town
No Etuluifand
15
Filed DEc. 13, 1920 Edward J. Bottoms
(Month) (Day) (Year)
REGISTRAR
14 John a. Buntes Informant ......
(Address) No Ctulidad
aldauf
Date of.
(Day)
(If nou-resident give eity or town and State)
2 FULL NAME
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, Civilengineer, 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 tho 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 DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. "Examples: Cere- brospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, men- inges, peritoneum, etc., Carcinoma, Sarcoma, etc., of .. . (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, 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,"" ctc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can be ascertaincd 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 townin 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, 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-301
The Commonwealth of Massachusetts
83
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
puddlesex
City or Town
lebehusford
No
St.,. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Hex ander Koste chio
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
( Usual place of abode)
Leogth of resideoce in city or town where death occurred
years
9
months
days.
How long in U. S., if of foreign hirth ?
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)
(Year)
7 AGE
Ycars
9
Months
Days
If LESS than
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation
mos.
or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kiod of work (h) General nature cfindustry, business, or establishment io which employed (or employer)
(c) Name of employer
CONTRIBUTORY
(SECONDARY)
(duration)
.yrs ...
mos.
ds.
18 Where was disease contracted if not at place of death?
Did an operation precede death ?
Date of
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed) Fred Waney.
, M.D.
(Address)
nach Chilicentral
Date
Dee
18
1920
( Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Russian
Westford
(Cemetery)
(City or town)
DATE OF BURIAL
Dec18,20
15 Src. 18,1920 Edward . Rolling
Filed. (Month) (Day) (Year)
REGISTRAR
20 UNDERTAKER
ya Healy
ADDRESS
Warford
21 | HEREBY CERTIFY that a satisfactory stao- dard certificate of death was filed with me BEFORE the burial or transit permit was issued Edward & Rotting
Official position.
Form Club
Date of issue cf permit Dear 18, 19 29 %.
Permit
1-6-'19. 150,000.
MEDICAL CERTIFICATE OF DEATH
Dee
18-
1920
(Day)
(Year)
17 I HEREBY CERTIFY, That I attended deceased from
that I last saw h
"
Dec 17
alive on
19.
20
.....
and that death occurred, on the date stated above, at.
7 a.
m.
The CAUSE OF DEATH was as follows :
Con culscino
.(duration)
.. yrs ..
... mos .. ds.
9 BIRTHPLACE (City)
Noch lebe hurford
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