USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 29
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genital," "Senile." cte.),
"Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shoek," "Uremia," "Weakness," ete., when a definite disease can be ascertained as the eause. Always qualify all diseases resulting from ehild- 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 such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and. consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations ou statement of cause of death approved by Committee ou Nomenclature of the American Medical Association.)
Cases for tho 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, ete.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ete.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R:303. G-'18. 50,000.
FORM R-301
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
86 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
State
Mass
Registered No. 1
City or Town
Chelmsford
No.
nilson
St. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Minst Sandnes Spalding
(a) Residence.
No.
Widen St. Chelmsford
St.
Ward.
(If non-resident give city or town and State)
Leogth of resideoce in city or towo where death occorred
20
ycars
months
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)
married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Ellente, Spalding
6 DATE OF BIRTH
March
116
1834 ( Year)
7 AGE 86 Years 9 Months 23 Days
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation.
.mos.
If LESS than
1 day, ........ hırs.
or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work .. Harmer
(b) Geoeral nature ofiodustry, hosiness, or establishment in which employed ( or employer )
(c) Name of employer
9 BIRTHPLACE (City)
Billerica
(State or country)
10 NAME OF
FATHER
Jacob Shoulding
11 BIRTHPLACE OF FATHER (City) (State or country)
Billerica
12 MAIDEN NAME OF MOTHER Mary ann Estey
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
mass.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Month)
Jan. 8
(Day)
1921
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
Jan
19.20, to.
Jan. 8
1921,
that I last saw h.It
alive on
Jan
1921,
and that death occurred, on the date stated above, at ..
2 P.m.
.m.
The CAUSE OF DEATH was as follows :
arteriosclerosis
Several years.
(duration)
.. yrs ...
CONTRIBUTORY
(SECONDARY)
(duration)
yrs ..
mos ..............
.ds.
18 Where was disease contracted
if not at place of death?
X
Did an operation precede death?
no.
Date of.
x
Was there an autopsy ?
What test confirmed diagnosis ?
Observation
(Sigoed)
amasa Howard
M.D.
(Address ).
Chelmsford, Mass.
Date.
Jan.
(Month)
(Day)
1921.
(Year)
14
Informant
Undlow Spalding
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Pine Ridge
Chalmeters
(Cemetery)
(City of town)
DATE OF BURIAL
Jan 11 1921
Filed (Month) (Day) (Year)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stao- dard certificate of death was filed with me BEFORE the horial or transit permit was issued Schwand J. Rothing
Official position
Down Clock
Date of issoe mit Jan, 11,1921
Permit
1-6-'19. 150,000.
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
MARGIN RESERVED FOR BINDING
PARENTS
- hot known
(Address )
Chelmsford
15 Jan. 11,192/ Edward . Roffing
20 UNDERTAKER Matter Perham
ADDRESS Cheerful.
No
(If in the Army or Navy of the United States, give rank, organization, etc.)
( Usnal place of abode)
( Month)
(Day)
DEVISED UNITED STATES STANNAR' CERTIFICATE OF DEATH
. 5 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 tho first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, cspecially 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, ete. 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 terni for the samo 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 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 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 thefamily 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 Aets 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 dicd; . . . 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 thereafterfurnish 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 como 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. Thcso 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 Commmuralth of Massachusetts STANDARD CERTIFICATE OF DEATH
87 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County .....
Middlegex
City or Town
Chelmsford
No.
State Ma.s.s ..
Registered No.
2
St.
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Isaac Leslie Bradley
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No ....
Evergreen St.
(Usual place of abode)
St.,
.Ward.
(If non-resident give city or town and State)
Length of residence in city or town where death occurred
20
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
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Elizabeth S. Bradley
6 DATE OF BIRTH
Oct. 13, 1863
( Month)
(Day)
(Year)
7 AGE 57 3 Monthis 8 Days Years
If STILLBORN, enter that fact bere
If STILLBORN, state period of uterogestation
mos.
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or
particular kind of work
carpenter
(b) General nature of industry,
business, or establishment in
which employed ( or employer)
builder
(c) Name of employer
9 BIRTHPLACE (City)
Plattsburg
(State or country)
N. Y.
10 NAME OF
FATHER
Josiah Bradley
11 BIRTHPLACE OF
FATHER (City)
Plattgburg
(State or country)
N. Y.
What test confirmed diagnosis ?
(Signed)
R.W. Janker
M.D.
(Address).
Lowell
22
1921
(Year)
14
Informant
Elizabeth S. Bradley
(Address)
Chelmsford Mass.
15
Jan. 23, 1921 Edward Robbins
Filed
( Month) (Day) ( Year)
REGISTRAR
21 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued Edward Sheffing
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
Edson Cem.
Lowell
(Cemetery)
(City or town)
Jan. 23 19
20 UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
Permil
Official
position
Kann Clerk
Date of issue of permit. San. 23 12/ No.
MARGIN RESERVED FOR BINDING
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 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.
1-6-'19. 150,000.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Monthi)
Jay.
21
(Day)
4921.
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
Jan, 11
19 26 to Jan, 21, 1921.
that I last saw hm
alive on
Jan. 21
, 1921.
and that death occurred, on the date stated above, at.
10 a .. m. . The CAUSE OF DEATH was as follows :
Septicemia
(duration)
Osteo myelitis
.mos ..
13 ds.
CONTRIBUTORY
( SECONDARY)
Left Tibia
(duration)
yrs.
mos.
15 %
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
yes
Date o
Jan. 14/121
Was there an autopsy ?
12 MAIDEN NAME
OF MOTHER
Delia Juba
13 BIRTHPLACE OF
MOTHER (City)
North Hero Vt.
(State or country)
Date
Jan.
( Month)
(Day)
PARENTS
male
WILLA CALLE QUE TEST""NDARD 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 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, Compositor, Architect, Locomotive engineer, Civil engineer, Stationary fircman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional linc 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 Housekcepers 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,""Dcbility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite diseasc 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 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
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 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.
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Mundolieux
). State
Immer
(City or Town)
Registered No. 467%
City or Town ..
No. Stealuna
St ... ...... Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
acura
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
( Usual place of abode)
Length of residence in city or town where death occurred
9
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
DV.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
mare
5a If married, widowed, or divorced HUSBAND of (or) WIFE of Edward Drewexto
6 DATE OF BIRTH
Mar1 5-1850
( Month)
(Day)
(Year)
7 AGE
Years
Months
Days
9
If LESS than 1 day, ........ his. or ........ min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work (b) Name of employer
9 BIRTHPLACE (City) (State or country)
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE OF FATHER (City) (State or country)
12 MAIDEN NAME TAME Jame Na
13 BIRTHPLACE OF MOTHER (City) (State or country)
Date
1
-240-121
(Month) (Day) (Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Tomar
(Cemetery)
(City or town)
DATE OF BURIAL Jauso 19 21
15
Filed. Jan. 26, 1921 Edward J. Rotfuns
(Month) (Day) (Year)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the hurial or transit permit was issued Sanand Rotting
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