USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 35
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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, 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 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 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
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massarinisetta
STANDARD CERTIFICATE OF DEATH
Chelmsford
1 PLACE OF DEATH
County ..
Middlesex
State Mass.
Registered No ...
(City or Town) +7-20
City or Town
Chelmsford
No.
2010 Middlesex St.
St ....
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Patrick E. Love
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No ...
20IO Middlesex St.
St.
Ward.
(If non-resident give city or town and State)
Length of residence in city or town where death occurred
26
years
months
-
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Omar 31-1921
Month)
(Day)
(Year)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Mary Murphy
6 DATE OF BIRTH -
(Month)
(Day)
( Ycar)
.Years
Months
Days
66
li STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
Retired - Motorman
9 BIRTHPLACE (City)
Cleveland
(State or country)
New York
10 NAME OF
FATHER
Michael Lowe
11 BIRTHPLACE OF
FATHER (City ).
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Sarah Hawkes
13 BIRTHPLACE OF MOTHER (City) (State or country) Ireland
Informant Mrs. Mary Lowe , Wife
(Address)
2010 Middlesex St. Chelmsford
15 ana / 1921 Justin R. Moore (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 Justin L. Mesare
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
St. Patrick's
Lowell
DATE OF BURIAL April 2, 192 I
(Cemetery)
(City or town)
20 UNDERTAKER
ADDRESS
324 Bought S
Official From elecke · issue .. position.
Date of
Permit
of permit apr. 1,192%
3 SEX Male 7 AGE PARENTS 14 Filed 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 (b) Name of employer
MARGIN RESERVED FOR BINDING
3.120. 20,000.
17 I HEREBY CERTIFY, That I attended deceased from april 10, 1921 , to ... man.20 19.2.2
I855
that I last saw h
alive on
Man 20
19.22 .. 5
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH was as follows :
If LESS than 1 day, ........ hrs. er ........ min. Unter Schencie
(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 ..
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
- M.D.
(Address).
aranan
31-21
Date
(Month)
(Day)
Year)
102
(Usual place of abode)
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
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 agc. 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 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 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," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite discase can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," ctc.
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.
1 :
1
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
COMMON
M THE LAWS OF THE MATH 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 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 Acts of 1910, Chap. 322.
No undertaker or other person shall bury a human body . . . until he has received a permit from the board of health or its agent, . . . or . . . from the clerk of the city or town in which the person died; .. . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written statement con- taining the facts required by law to be returned and recorded, which ... shall be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in 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 deccased, 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-305
The Commonmuralth of Massachusetts
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
1 PLACE OF DEATH (ISSUED UNDER THE PROVISIONS OF REVISED LAWS, CHAPTERS 24 AND 29)
County
Middlesex State Mars
Registered No. SI
$$14
Registered No.
(Place of death)
(Place of residence)
St., .Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(If in the Army or Navy of the United States, give fank, organization, etc.)
(a) Residence.
No.
( Usual piace of abode)
Leogth of resideoce io city or town where death occorred
years
months
days
How long in U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH March 2 (Month)
(Day) 1921 (Year) }
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
hoving t.
nov.
(Month)
(Day)
Years
4
Months 20 Days
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work (h) General oafure of industry, business, or establishment io which employed (or employer) (c) Name of employer
none
Chelmsford
Buyany
11 BIRTHPLACE OF
FATHER (City)
Chelmsford
(State or country)
12 MAIDEN NAME} OF MOTHER Hannah Bradford.
13 BIRTHPLACE OF MOTHER (City) Salem
(State or country ) w.12
Fil nov. 29, 199 p
sity or welin
ti tras of city of town where Lat Scanned 7/ position
Filed afr. 9 .1921. (Month) (Day) (Year)
Justin L. Noone Registrar of city or towo where deceased resided
(See reverse side for additional space)
18 Where was injury sustained
So Chelmsford
(Signed)
ThomasB Smith
Powell
(Address)
M.D.
Marc.
22
Date
(Month)
(Day)
( Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Hart Pond Com, Chalmers
DATE OF BURIAL mar. 231921. (month) (Day) ( Year)
ADDRESS
20 UNDERTAKER
Walter Perham Chelmsford
21 Burial permit Issued by
Official
22 Date of issue
9.'18. 10,000.
MARGIN RESERVED FOR BINDING
2 FULL NAME 3 SEX m. 6 DATE OF BIRTH 7 AGE 8 10 NAME OF FATHER PARENTS 14 Informant (Address) 15 should be carefully supplied. AGE should be stated EXACTLY. MEDICAL EXAMINERS should state CAUSE OF See reverse side for extracts from the laws of the Commonwealth and instructions. DEATH in piain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information 9 BIRTHPLACE (City) (State or country)
103
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
City or Town.
howell
Henry Harrise
No ..
St.
Ward. Chelmsford Mass
(If non-resident giveeity or own and State)
4 COI.OR OR RACE
res.
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) Married
17 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof 1839 are as follows : fractures of temur (Year) If LESS than I day. ........ hrs. Humerus. accidental Wwe to fall from thep. or ........ min.
Medical Examiner for
5th wit middlesex
1921.
-mart.
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 stand- ard 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 ean be elassified 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 elerk 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 containing the facts required by law to be returned and recorded, which ... shall be accompanied by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thercof a certificate 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 insuffi- cient, 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 certifieate 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 permit is so given and the physician who certifies to the cause of death shall thercafter furnish for registration any other necessary infor- mation 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 residenee, 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 sup- posed 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 ealls for the observanee of the following rules of praetiee:
(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 sueb deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without. recent medieal attendance or whose physician is absent from homo when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths eaused directly or indirectly by traumatism (including resulting septieemia), and by the action of chemieal (drugs or poisons), thermal, or eleetrieal 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.
COPIES OF RECORDS OF DEATHS OF NON-RESIDENT DECEDENTS
The clerk of each eity and town shall forthwith make certi- fied copies of the records of all . . . deaths recorded during the previous month, if the . . . deceased [ was a resident] of any other eity or town in this commonwealth or in any other state at the time of said ... dcath, and transmit them. to the elerk of the eity or town of which sueh . .. deceased person [was] resident at the time of the said ... death ... and the elerk of a city or town in this commonwealth so receiving such certified copies, or certified copies of . .. deaths, from the elerk of a eity or town without the commonwealth, shall record the same. - Revised Laws, Chap. 29, Sec. 13, as amended by Acts of 1910, Chap. 93, Sec. 3.
DESCRIPTION (for unknown person)
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
( City ar town), +03
County
Middleser
State
mars
Registered No.
1911
City of Town well
No Show Hospital
(Plage pf residence)
St., .. .Ward
2 FULL NAME
(If death occurred in a hospital or institution, give its FAME instead of street and number) Ruth Bernicebutton
(a) Residence.
mars
City or Town Chelmsford No.
St.
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
days
How long in U. S., if of foreign birth?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year Mar, 22 1921.
17
I HEREBY CERTIFY, That I attended deceased from
19.
to.
March 16
2, to Mar, 22, 1921,
that I last saw har ... ) alive on
21
...
1921.
and that death occurred, on the date stated above, at
12.2
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.) appendicitis
6
.ds.
9 BIRTHPLACE (city or town)
(State or country) maleb
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city or tokn
(State or country)
masa
12 MAIDEN NAME OF MOTHER Georgia Libby
What test confirmed diagnosis ?...
(Sigoed)
H. It. Lunner
M.D.
3. 29 192 ( Address)
Lowell
14 Father
Informant (Address)
Chelmsfordimas !!
15
Filed mar. 23
FORestrar of city of town where death occurred
apr. 9
Filed 19 2/ Justin R. Konec
Registrar of city or town where deceased resided
............ yrs.A
CONTRIBUTORY Septic Peritonitis
(SECONDARY)
(durAtion)
4
... mos.
.ds.
18 Where
if not at place of death ?
Chelmsford.
Did an operation precede death? yes
Date Mar. 19,1921.
Was there an autopsy?
Tho.
13 BIRTHPLACE OF MOTHER (city or towa)
(State or country)
mas
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL Forefathers Chelmsford mar 24 19 21
20 UNDERTAKER
ADDRESS
W. Tenham Chelmsford
MARGIN RESERVED FOR BINDING
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statoment of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
3 SEX
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (grite the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year) les 18, 1917.
7 AGE
3
Years
3
Months
4
Days
If LESS than
1 day, ........ brs.
or ....... min.
If STILLBORN, enter that fact bere
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work
(b) General natore of industry, bosioess, or establishmeot in which employed (or employer) (c) Name of employer
Chelmsford
104 Powell
1 PLACE OF DEATH
Registered No.
4 COLOR OR RACE
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