USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 37
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8-'20. 35,000.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
March 16
1921
co.
1921
that I last saw her alive on
april
5-
1921
and that death occurred, on the date stated above, at
9.a
m.
The CAUSE OF DEATH. was as follows : -
Chimica recenticial
.(duration)
Serial
.mos.
.ds.
CONTRIBUTORY.
(SECONDARY)
.. yrs.
......
Informant
alice M. Stearns
(Address)
Chelmsford
15
apr. 8 1921 celine L. Neroce
(Month) (Day) (Year)
REGISTRAR
State
Mass
(City or Town)
Registered No.
2223
( Usual place of abode)
6
192/
(duration)
.... yrs ................. mos ...
14 ds.
20
FORM R.30
Exact statement of OCCUPATION is very important. See instructions and extracts from the laws on back of certificate.
in piain terms, so that it may be properly classified.
PHYSICIANS should stato CAUSE OF DEATH should be carefully supplied. AGE should be stated EXACTLY. SI SIHL- XNI NOVIS BNIOVANA HLM XINIVT ILIUM-
ĐNIONI8 803
0-2 1000.
/
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, irrcspective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should 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," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ctc. 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. Carc should bo 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 indefinitc); Tuberculosis of lungs, men- inges, peritoneum, etc., Carcinoma, Sarcoma, etc., of ... .. (name origin; "Cancer" is less definite; avoid uso 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- inittec 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 deccased, 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. 522.
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- eate 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. 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 niake 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. 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.
i
FORM R-301
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
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS,
STANDARD CERTIFICATE OF DEATH
(City or Town)
2324
7
City or Town
St.,.
......
.. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Thanfald
(a) Residence. No
(Usual place of abode)
Length of residence in city or town where death occurred
1
years
months
(If non-resident give city or town and State)
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 Chic
(Month)
(Year) 19 1921 (Day)
17 I HEREBY CERTIFY, That I attended deceased from
19
1921, to Opene 19
1921
that I last saw h alive on 19
and that death occurred, on the date stated above, at m. The CAUSE OF DEATH was as follows :
(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 ?
120
What test confirmed diagnosis ?
(Signed)
M.D.
(Address). 20 checifica
aprie
20
1921
(Month) (Day) (Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL Apar 2 9/201
(Cemetery)
(City or town)
20 UNDERTAKER
ADDRESS
File ........ (Month) (Day) (Ycar)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued
ih me Justin Limone
Official Van cleck
Date of issne of permit apr. 2192#
3 SEX
4 COLOR OR RACE
C
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Fred B.Builton
6 DATE OF BIRTH
(Month)
16-1890 (Day) (Year)
7 AGE Years 31
Months
3
Days
3
If LESS than
1 day, ........ hrs.
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
Marione Monson.
-
PARENTS
11 BIRTHPLACE OF FATHER (City) (State or country)
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF MOTHER (City) (State or country)
2.
14
B. Bullan
Informant.
(Address)
15
211921 Justin Linerre
-
6-'20. 20,000.
The Commonwealth of Massachusetts
108
1 PLACE OF DEATH County.
State
Registered No.
8Bultos.
(If in the Army or Navy of the United States, give rank, organization, etc.) St. Ward.
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 lino will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in 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 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 "Lahorer," "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 entercd 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 domestie service for wages, as Servant, Cook, Houscmaid, 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: Ccre- 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, mcn- 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," 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.
Certificates will be returned for additional information which give any of the following dissasss, 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.
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 contractcd, tho 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 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 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.
1
C
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 ths action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from dissase 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-303
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information for extracts from the laws relative to the return of certificates of death. so that it may be properly classified under the International Classification of Causes of Death. See reverse side should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms,
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
(City or 'lowL) 36
County
Middlesex
State
mais.
Registered No.
St ..
Ward
-{Ifdeathoccurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
South
(If inthe Army or Navy of the United States, give rank, organization, etc.)
St.,
.Ward,
(a) Residence.
No.
(Usual place of abode)
Length of residence in city or town where death occorred
years
months
days
How loog in !. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Make
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED OR
DIVORCED (write the word)
married
16 DATE OF DEATH.
(Month)
(Day)
(Year)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Emma Bartlett
6 DATE OF BIRTH
aug
( Month)
(Day)
(Year)
7 AGE
78
Years
Months
8
Days
O
If LESS thao 1 day, ...... hrs. cr ....... min.
17 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows : Mul wound of hand, accidentali
followed by Samural Septicemia.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kiod of work
(b) Name of employer
Hardware Merchant
9 BIRTHPLACE (City)
Chelmsford
(State or country)
10 NAME OF
John C. Bartlett
FATHER
11 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Cambridge
12 MAIDEN NAME
Maria adams
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City)
Chelmsford
(State or country)
14 Mro a.S. Scolonia
(Address)
Informant.
Chelmsford
15
Filed
(Month) (Day) ( Year)
REGISTRAR
21 Burial permit issued by. .. it actrice T. Mendes Official position
(See reverse side for description for unknown person)
Where was injury
216 Antrags- Loures.
if not at place of death?
(Sigoed)
M.D.
(Address)
84 Middlesex Rx, Rowill
5th Seit, Le dal ry Coo Wan.
Medical Examiner
24
1921,
Date
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, or REMOVAL
Horefathers
Chelmsford
DATE OF BURIAL a 126 1921
(Cemetery)
(City of town)
louth) (Day) (Year)
ADDRESS
Chelmsford
Walter Parham
22 Date of Cfr. 251480 mit issue ...
1
109
1 PLACE OF DEATH ^
(ISSUED UNDER THE PROVISIONS OF REVISED LAWS, CHAPTER 24)
Cheveux ford
No.
City or Town,
You adans Bartull
MEDICAL CERTIFICATE OF DEATH
april
24 1921
24
122
PARENTS
10-'20. 10,000.
MARGIN RESERVED FOR BINDING
( If non-resident give city or town and State)
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 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 state- ment containing the facts required by law to be re- turned and recorded, whichi . .. shall be accompanied by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as herein- after 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 & 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 persen to whom the permit 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 elerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town elerk 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 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 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 supposably 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 clectrical agents, and deaths following abortion, but also deaths from disease resulting from in- jury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
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