USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 28
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(State or country)
10 NAME OF
Serque Rostechlo
FATHER
PARENTS
11 BIRTHPLACE OF
FATHER (City)
Russia
(State or country)
12 MAIDEN NAME
OF MOTHER
antonina Dedolka
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
14 austin Healy
Informant. (Address)
MARGIN RESERVED FOR BINDING
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
STANDARD CERTIFICATE OF DEATH
State
mars
Registered No. 72
Ward.
(If non-resident give city or town and State)
16 DATE OF DEATH
(Month)
19
17 1920
1 day ......... hrs.
RE:
++ STATES STANDARD CERTIFICATE OF DEATH
Approved by U. S. Census and American Public Health Association!
Statement of occupation. - Precise statement of occupation is very iniportant, 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 engincer, Civilengineer, Stationary fireman, ctc. Butin many cascs, 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 laborcr, Laborer - Coal mine, etc. Women at home, who are engaged in the dutics 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 discase. 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 nced 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,""Heartfailure," "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- mittce 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, gangrone, 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 agc, 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 Aets 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 cierk, . . . 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 ezaminer 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. 88.
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 disabied by recognized disease, and those of persons found dead.
FORM R-301
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
84 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County ..
Middlesexa
State .Ma.s.s.
Registered No.
73
City or Town
Chelmsford
No.
Turnpike .... Rd.
(If death occurred in a hospital or institution, give its NAME instead of street and number)
St ..
.. Ward
2 FULL NAME
Ruth Nettie Adams
(If in the Army or Navy of the United States, give rank, organization, ete.)
(a) Residence.
No.
Turnpike .... Rd.
St.
Ward.
(If non-resident give eity 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
mouths
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
Sept. ( Month)
(Day)
(Year)
7 AGE 1y Years 2
Months 2y
Days
If LESS than
1 day ......... hrs.
or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work. At home
(b) General nature ofindustry, business, or establishment in 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 ?
no
Was there an autopsy ?
no -
What test confirmed diagnosis?
Microscopie Section .
(Signed)
Autumn T. covaria.
M.D.
(Address).
Celulmotora, Inaos!
Date
Drc.
( Month)
(Day)
221
1920.
( Year)
14
Informant
Harry F. Adams ( father)
(Address )
Chelmsford,
Mass
15 DEC. 28, 1920
Filed
(Month) (Day) (Year)
REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Pine Ridge --
Chelmsford
DATE OF BURIAL
Dec.24 1920
(Cemetery)
(City or town)
20 UNDERTAKER
ADDRESS
Walter Perham, Chelmsford, Mas 8
21 1 HEREBY CERTIFY that a satisfactory stau- dard certificate of death was filed with me BEFORE the burial or transit permit was issued Edward S. Pot bin
Official Down Clock
Date of issne of permit Sec, 28,1420 No.
Permit
MARGIN RESERVED FOR BINDING
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
1-6-'19. 150,000.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec. 22
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
aug. 25
19
20.
to ..
Drc. 22
, 19
20.
23
1901
that I last saw her alive on
Dec. 22
1920.
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH was as follows :
.
Carcinoma of cereal
Slands of Liver -
about
( duration)
2
.yrs ....
.. mos ..
.ds.
9 BIRTHPLACE (City)
Chelmsford.
(State or country)
Middlesex CÓ.
Mass.
10 NAME OF
FATHER
Harry F. Adams
PARENTS
11 BIRTHPLACE OF
FATHER (City)
Lowell, Mass.
(State or country)
12 MAIDEN NAME
OF MOTHER
Lottie F. Peters
Date of
13 BIRTHPLACE OF
MOTHER (City)
Blue Hill, Maine.
(State or country)
If STILLBORN, enter that fact here If STILLBORN, state period of uterogestation ........... mos.
1920
( Usual place of abode)
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. Tho 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, o. 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 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 tho 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 DEATHI (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 uso 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. 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 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 tho 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 mako 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 diseaso 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 deathis 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
1 PLACE OF DEATH
County ....
Middlesex
State ....
Massachusetts
City or Town
Tewksbury
No ..
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Charles .... Earle
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.
(a) Residence. State
(Usual place of abode)
Length of residence in city or town where death occurred
-
-
years
2 months
4
days
How long 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)
Widower
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Mary LaMone
-
6 DATE OF BIRTH (month, day, and year)
Oct.15, 1849
7 AGE
Years
71
Months
2
Days
2
1 day, ........ hrs.
or ........ min.
If STILLBORN, enter that fact here
16 DATE OF DEATH (month, day, and ycar)
Dec. 17
19 20
17
I HEREBY CERTIFY, That I attended deceased from
Oct. 13
19 .. 20, €0
Dec. 17
20
19
that I last saw h .... i.m ...
Dec. 17
192.0
and that death occurred, on the date stated above, at
7:300
If LESS than
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.)
Arteriosclerosis
(duration)
10
.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 ?.
Date of
Was there an autopsy?
No
What test confirmed diagnosis?
Examination
(Signed)
John P. Bouler
M.D.
12/7, 192 (Adress)
DATE OF BURIAL
14 Informant Hospital Records 1
(Address) Infirmary. Temutesteur.
15 Filed12/17, 19204
Kaffe Registrar of city of town where Beath occurred Edward Y. Robbing
Filed fan
192/
Registrar of city or town where deceased resided
8,5
Tewksbury
( City or town)
Registered No ..
403
(Place of death)
Registered No ..
74
(Place of residence)
State Infirmary
St.,
Ward
MARGIN RESERVED FOR BINDING
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be 80 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.
PARENTS
10 NAME OF FATHER
William Earle
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
England
12 MAIDEN NAME OF MOTHER Mary Simms
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
England
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
CHAPTER 77 REVISED LAWS
19
20 UNDERTAKER
ADDRESS
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particolar kind of work
Laborer
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town)
Portland
(State or country)
Maine
MEDICAL CERTIFICATE OF DEATH
City or Town
Chelmsford
No.
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and'American Public Health Association]
Statement of occupation. - Preciso statement of occupa- tion is very important, sc"." titulness 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, c. 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 inay form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., 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- 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 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 "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, ete., Carcinoma, Sarcoma, ete., of _.
(name origin; "Caneer" 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 symptomatie), "Atrophy," "Col- "Debility "?' ("Con- lapse," "Coma," ""Convulsions,"
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