USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 44
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(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, tho 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
127
STANDARD CERTIFICATE OF DEATH
1 PLACE OF
DEATH .
Middlesex
County
City or Town
Chelmsford
No.
Henry
(If death occurred in a hospital or institution, give its NAME instead of street and number) Reed
2 FULL NAME
Otis
(a) Residence.
No.
Turnpike Road
St.,
Ward.
(If non-resident give eity or town and State)
( Usual place of abode)
Leogth of resideoce ia city or town where death occurred
4
years
months
days.
How long in U. S., if of foreigo birtb ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH May ( Month)
3 1854
(Day)
( Year)
Years
67
Months
/
Days
4
if LESS thao 1 day, ........ his. or ........ min.
If STILLBORN, eoter that fact bere
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind ot work
Farmer
9 BIRTHPLACE (City)
Tyngsboro
(State or country)
mass.
abraham Reed
11 BIRTHPLACE OF
Westford
FATHER (City)
(State or country)
mass
12 MAIDEN NAME
OF MOTHER
Mary Cummings
13 BIRTHPLACE OF
MOTHER (City)
Tyngsboro
(State or country)
mass
( Month)
(Day)
(Year)
14 Mro. Ida Foss
(Address)
Chelmsford, mas
15 June 9 1921 Justin L Moon
Filed ..
(Month) (Day) (Year)
REGISTRAR
21 ] HEREBY CERTIFY that a satisfactory stan- - dard certificate of death was bled with me- BEFORE the horial or transit permit was issued
isfactory la Justice L. illaare
Officialyou Check position.
Date of issoe of permit. 6/9/2/
Permit
No
8-'20. 35,000.
MEDICAL CERTIFICATE OF DEATH
1921
16 DATE OF DEATH,
(Month)
(Day)
(Year)
17 HEREBY CERTIFY, ThatI 21 το
Strene 1
19
1
21
21.
that I last saw h. IM alive on
19.
m.
6
21
and that death occurred, on the date stated above, at.
The CAUSE OF DEATH was as follows : Myocarditis -
(duration)
2
... yrs.
... mos ..
ds.
activo sclerosis
-
CONTRIBUTORY
(SECONDARY)
(duration)
.. yrs ................. mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
220.
Was there an autopsy ?
no.
What test confirmed diagnosis ?...
Antunti Scoloria
M.D.
(Signed)
(Address).
Chelmsford, mass.
Date.
6-81-1921.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Thompson- Tyngsboro, mass
(Cemetery)
(City or town)
DATE OF BURIAL
June 10
1921
20 UNDERTAKER
Halter Perham
ADDRESS
Chelmsford.
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information MARGIN RESERVED FOR BINDING
3 SEX male 7 AGE 10 NAME OF FATHER PARENTS Informant. should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH (b) Name of employer 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
(City or Town)
42
Registered No.
State.
mass
St ...
.Ward
(If in the Army or Navy of the United States, give rank, organization, etc.)
attended deceased from
June
1
Date of.
EXT.
"TS
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, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The 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 servico 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 disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary causo.
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 deccased, 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, thie 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; . .. nosuch permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written statement con- taining the facts roquired 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 tho 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.
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
( City or town) 744
1 PLACE OF DEATH
Registered No ....
County.
middlene
State
masal.
Registered No.
4-3
(Place of residence)
City or Town
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
(a) Residence.
State.
masa,
City or Town
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
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Singly
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year Chung 9. 1912
7 AGE
Years
Mouths
Days
If LESS than
1 day, ........ hrs.
or ........ min.
If STILLBORN, eoter that fact bere
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kiod of work
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town) Littlet Littleton
(State or country)
10 NAME OF FATHER
more
18 Where was disease contracted
if not at place of death ?
4
Did an operation precede death? LeLI
Date of June 11 /92
Was there an autopsy?
What test confirmed diagnosis?
(Signed)
I. h. Jag
6.15, 1921, (Address)
19 PLACE OF BURIAL CREMATION, OR REMOVAL Streeph, Chelmsford.
DATE OF BURIAL
June 16 0 2/.
15 Filed Rene 16
AL Registrar of city or town where death occurred Filed June 30 192% Justice R. more
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) June 13 19 21.
17
HEREBY CERTIFY, That I attended deceased from
11
19.
21
to
19
June
13
21
that I last sawh Oralive on
le
13
19
21.
and that death occurred, on the date stated above, at m 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 gide for additional space.) Peritonitis
ONTRIBUTO
(SECONDARY)
Mange
.(duration)
.............. yrs ...
.mos ................. ds.
.. (duration)
...... yr's.
mos .. ........... .ds.
11 BIRTHPLACE OF FATHER (city or towe
FallRiver
(State or country) masa.
12 MAIDEN NAME OF MOTHER a Lacombe.
Putteton
13 BIRTHPLACE OF MOTHER (city or toware (State or country) W.H.
14 father
Informant (Address) Chelmsford Mars.
20 UNDERTAKER
Jos. albert.
ADDRESS
Lowell.
MARGIN RESERVED FOR BINDING
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be 1
of certificate.
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,
128 Lowell
(Place of death)
St. Ward
(If in the Army of Navy of the United States, give rank, organization, etc.) O
10
4.
PARENTS
M.D.
IN
Statement of occupation. - Freeise statement vi occupa- tion 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, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on 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 minc, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domcstie 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 faet may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. -- Namc, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always thic same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid usc of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- ficd, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, etc., of_
(name origin; "Caneer" is less definite; avoid usc of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, ete. The contributory (secondary or inter- current) affection nced not be stated unless important. Example: Measles (discasc causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as " Asthenia,'
"Anemia" (merely symptomatic), "Atrophy," "Col-
lapse," "Coma," "Convulsions,"
"Debility"
(“Con-
genital," "Scnile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock,"Uremia," "Weakness," ete., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from child- 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 consequenecs (c. g., sepsis, tetanus) may be stated
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, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or onc supposed to bc due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTIIER STATEMENTS BY
PHYSICIAN.
E 303. 6-'18. 50,000.
FORM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
State
Mark
Registered No.
44
St.,. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Mehitable Sage Gibson
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
Barthur St.
St.,
Ward.
Lowell mark
(If non-resident give city or town and State)
( 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
months days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Nidow
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Moses pilson
6 DATE OF BIRTH
aprix
( Month)
(Day)
(Year)
Years
Months
2
Days
11
1 day, ........ hrs.
or ....... min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, nr
particular kind of work.
at home
9 BIRTHPLACE (City)
Pelham
( State or country)
7.4.
10 NAME OF
FATHER
nathan Sage
11 BIRTHPLACE OF
FATHER (City ).
Pelham
(State or country)
n.M.
12 MAIDEN NAME
Melistable Woodbury
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City)
Salam
(State or country)
n. H.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?.
no.
Date of.
Was there an autopsy ?
70.
What test confirmed diagnosis ?...
Auchan I. Scolonia
M.D.
(Signed)
(Address).
June 21
Chelmsford, mans.
1921.
Date.
7(Month)
(Day)
(Year)
19 PLACE OF BUBAAL, CREMATION, OR REMOVAL
Pelham Cem.
Pelham M.H.
(City or town)
(Cemetery)
20 UNDERTAKER
Matter Perham
ADDRESS
Chelmsford
21 I HEREBY CERTIFY that a satisfactory stan-
Official
.position.
brou deck
Date of issue nf permit 6/23/2/ No
Permit
BEFORE the burial nr transit permit was issued
MEDICAL CERTIFICATE OF DEATH
June
21
1921.
(Day)
(Year)
17 I HEREBY CERTIFY, Thay I attended deceased from
June-58
1921, to.
June 21 1921.
that I last saw her
alive on
(me 21
, 19 21
and that death occurred, on the date/stated above, at
7:30Pm.
if LESS than The CAUSE OF DEATH was as follows : Caterio Sclerose -
Murconditio -
(duration)
............
.. yrs ...
.. mos ........
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
............ yrs ...............
mos.
.ds.
14 Tro alfred P. Sawyer
(Address)
Chelmsford
15 Juice 23 1924 Justin &. Moore
(Month) (Day) (Year)
REGISTRAR
8-'20. 35,000.
3 SEX Hemale 7 AGE 86 PARENTS Informant. 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
N. B. - WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information MARGIN RESERVED FOR BINDING
The Commonwealth of Massachusetts
129
(City or Town)
1 PLACE OF DEATH
County.
City or Town
Chelmsford
No.
16 DATE OF DEATH.
(Month)
10
1835
....
DATE OF BURIAL
Secue 24 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 tho 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 materialfavorked on may form part of the second statement. Never return "Lahører," "Foreman," "Manager," "Dealer," etc.,without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine Women at bome, who are engaged in the duties of the house- hold onfy (not paid Housekeepers who receive a definite salary), may be entereras Housewife, Housework, or At home, and children, not gainfully employed, as. At school or At home. Caro 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 "Asthcmia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- uition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
KEIURN Vr VERIFICA Vr HEIN
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. 322.
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