USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 30
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Official position
Con Clerk
Date of issue of permit .. Sm. 261921
Permit
No.
.......
!
11-13-'19. 50,000.
The Commonwealth of Massachusetts
88
(duration) ... yrs ...
mos.
2
ds.
CONTRIBUTORY
(SECONDARY)
Serral (duration) 1 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.
What test confirmed diagnosis Anna 4. Persona (Signed).
(Address).
Chaqueford -11000.
M.D.
14 Edward Drevet-
Informant (Address)
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
San 24-1921
(Month)
(Day)
(Year)
17 HEREBY CERTIFY, That)I attended deceased from
19.91 ... , 10.
23
Jan. 24
1921
that I last saw h
en
alive on
Stan. 24
1921.
and that death occurred, on the date stated above, at. 12:30Pm
The CAUSE OF DEATH was as follows,: Acute Gastrito
70
St.,
.Ward.
(If non-resident give eity or town and State)
MARGIN RESERVED FOR BINDING
20 UNDERTAKER DA. Hun Blake Juck ADDRESS
1
REVISED UNITED STATES STANDARD CERTIFICATE ( FATH
[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. 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 he 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 he ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deccased, furnish for registration a standard certificate of death, stating to the best of his knowledge and bclief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contractcd, the duration of his last illness, when last seen alive hy 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 dicd, his name and residence, if known, otherwise a description of such person as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are 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, hut 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
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
89
1 PLACE OF DEATH
County.
Middlesex
State
Mass
Registered No.
.# 7673 4
City or Town
Chelmsford
No ..
Littleton
St .. .Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Elizabeth S. Saunders
(If in the Army or Navy of the United States, give rank, organization, ete.)
(a) Residence.
No.
Chelmsford
( Usual place of abode)
Length of residence in city or town where death occorred 20
years
.St.
.Ward.
(If non-resident give eity or town and State)
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)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
Jan 21
18.30
( Month)
(Day)
(Year)
Years
91
Months
0
Days
5
If LESS than
I day, ........ hrs. er ........ min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
At Home
9 BIRTHPLACE (City)
Waterford
(State or country)
Maine
10 NAME OF
FATHER
Amos Saunflers
11 BIRTHPLACE OF
FATHER (City)
Waterford
(State or country)
Maine
12 MAIDEN NAME
OF MOTHER
Alyvia Stone
13 BIRTHPLACE OF
MOTHER (City)
Groton
(State or country)
Mass
Date
Lec
27
1921
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Forefathers
Chelmsford
(Cemetery)
(City or town)
20 UNDERTAKER
W.Herbert Blake
ADDRESS
Lowell
21 I HEREBY CERTIFY that a satisfactory stan-
BEFORE the burial or transit permit was issued : Edward J. Roffing
Official Conn Click .position ...
Date of issue
Permit
Jan 28/92 No
1
11-13-'19. 50,000.
Informant
Clara M. Saunders
(Address)
Chelmsford
Mass
15
Jan, 28, 1921 Edward & Roffing
(Month) (Day) (Year)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jan 26 1921
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
6
, 19 210
Jan 26
19.
2/
that I last saw her alive on
Jan 26
192.
and that death occurred, on the date stated above, at
7. 45 R.
The CAUSE OF DEATH was as follows :
Bronchofumaria.
.(duration)
... yrs ...............
mos
20
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
.. yrs.
mos ..
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
20
Date of.
Was there an autopsy ?
no
What test confirmed diagnosis ?
Daniel & Ellison
(Signed)
M.D.
(Address)
Stanemnada Formell
DATE OF BURIAL
Jan 29
19
MARGIN RESERVED FOR BINDING
3 SEX Female 7 AGE PARENTS 14 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 (h) Name of employer
months
Chelmsford
(City or Town)
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 ags. 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 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 "Laborcr," "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, ete., 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 definits 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 causs 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.
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, ths duration of his last illness, when last seen alive by ths 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 hs 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 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 ths clerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clark or to the city registrar in the place where the deceased died, his name and residencs, 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 observancs of the following rules of practice:
(1) Attending physicians will certify to such deaths only as thoss 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 deatlıs 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
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
90
Chelmsford
(City of Town)
State
Registered No.
5
St. .Ward
2 FULL NAME McQuade
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
Cottage Row
St.,
.Ward.
(If non-resident give city 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
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
Years
Months
Days
If LESS than
1 day ......... hrs.
or ....... min.
If STILLBORN, enter that fact bere
Stillborn
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
John J. McQuade
11 BIRTHPLACE OF
FATHER (City)
Lowell
(State or country)
12 MAIDEN NAME OF MOTHER Florence Finch
(Signed)
Frank & Philli.
M.D.
(Address ).
Date.(.)
February
(Month)
(Day)
1921 (Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
St. Patrick's (Cemetery)
Lowell (City or town)
DATE OF BURIAL Feb. 3 192I
15 Feb. 3. 192/(Odmand , Colori.
Filed (Month) (Day) (Year)
21 | HEREBY CERTIFY that a satisfactory stan-
Edward & Rolfr. REGISTRAR
James F. O' Donnell & Sons
Official John Clark position
of permit.
Date of issue S26.3,192/
Permit
BEFORE the burial or transit permit was issued
MEDICAL CERTIFICATE OF DEATH
/
1926
(Day)
(Year)
17 I HEREBY CERTIFY, That I attended deceased from Jan 31 1920 Feh 1 to ...
that I last saw h
×
alive on
19
×
and that death occurred, on the date stated above, at
X
m, The CAUSE OF DEATH was as follows:
still Born
(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 ?
Date of. 1
Was there an autopsy ?
What test confirmed diagnosis ?.
13 BIRTHPLACE OF MOTHER (City) England
(State or country)
14
John J. McQuade
Informant (Address) Www North Chelmsford
20 UNDERTAKER
ADDRESS Market St.
No ..
-
6-'20. 20,000.
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. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
MARGIN RESERVED FOR BINDING
PARENTS
Checknord
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County.
Middlesex
City or Town
Chelmsford
No ..
Cottona=07
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(Usual placc of abode) .
16 DATE OF DEATH
(Month)
, 1921
1921
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. 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, 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, Houscwork, 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 definito 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 tho 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.)
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