USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 45
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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 deccascd, or as to the manner or cause of the death, which tho 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 Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Middlesex
State Mars
City of Town
(So) Chelmsford,
No. Acton Road
St.
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Ernest & Clark
(a) Residence.
No.
Action Roads
Ward.
(If non-resident give city or town and State)
Length of residence in city or town wbere death occurred
7 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
Muito.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Singles
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH Sept. ( Month)
(Day)
( Year) Y
7 AGE
13
Years
Months
9
Days
12
if LESS than 1 day, ........ hrs. or ........ min.
If STILLBORN, enter that fact bere
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
School Boy
(b) Name of employer
Killingly,
9 BIRTHPLACE (City) (State or country)
Conn.
PARENTS
10 NAME OF
FATHER
Ernest E. Clark
11 BIRTHPLACE OF
FATHER ( City).
great Falls,
(State or country)
N. 71.
12 MAIDEN NAME
OF MOTHER
Ida Jí. Parkincom
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Masa
New Bedford,
(Address).
Date
(Month)
(Day)
(Year)
14 Mira. Ida Tiblack
Informant.
(Address )
Providence, R. g.
15 un 221971 Quetras Finoad (Month) (Day) (Year) REGISTRAR
21 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial cr transit permit was issued
me Justin timeson Official Jour Check
of permit.
Sowell, Dass.
Permit
6-'20. 20,000.
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
de ce, A. J.
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information
1
that I last saw blev alive on 22 1921 and that death occurred, on the date stated above, at 400A m. The CAUSE OF DEATH was as follows : r Char. Endocarditis
(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 ?
20
Was there an autopsy ?
200
What test confirmed diagnosis ?
(Signed)
Harry & Cobens
M.D.
2% 1944
DATE OF BURIAL
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Danielson-Tavielson, boom June 25,1921.
(Cemetery)
(City or tofvn)
20 UNDERTAKER
Grow Healey.
ADDRESS
22
(Day)
1921
(Year)
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
17 I HEREBY CERTIFY, That I attended deceased from May 1 19790, co Juez 22 1921
10. 1907
So Chelmsford (City ou Town)
Registered No
45
(Ifin „y or Navy of the United States, give rank, organization, etc.)
( Usual place of abode)
MARGIN RESERVED FOR BINDING
-
Date of.
-
Statement of occupation. - Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on tho first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, 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," "Forcman," "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, 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 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 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 oausing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
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 discase 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 lieu thereof a certifi- cate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner „. only shall make such certificate. . . . The person to whom the per- mit is so given and the physician who certifies to the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise a description of such person as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are supposed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from diseaso 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, tho sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
FORM R-301 .
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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH County Headless
maso
State hath heleen ford; St.
.Ward (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(a) Residence. No ... ( Usual place of abode)
: Length of residence ia city or town where death occurred years
'smonths 4 days.
How long in U. S., if of foreign birth ?
years
months - days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Jewali Mits
4 COLOROR RACE
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word)
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH
July ( Month)
4. 19-1.
(Day)
(Year)
7 AGE
Years
Months
Days
4
If LESS than 1 day, ........ his.
or ....... mio.
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)
mars-
PARENTS
11 BIRTHPLACE/DE FATHER (y) ... (State or country)
Maso
12 MAIDEN NAME OF MOTHER
Elizabeth, Jardin
13 BIRTHPLACE OF MOTHER (City) (State or country)
Wrangler Thaco
14 John
Informant (Address)
15 July 8 1991 Quetil e. noor (Month) (Day) (Year) REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stan- Card certificate of death was fled with me Justice Retrof. BEFORE the burial or transit permit was issne
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH. (Month)
Analy
8-
1921
(Day)
(Year)
17 :.
1
HEREBY CERTIFY, That I attended deceased from
19 .. 21 , co
, 1921.
that I last saw he alive on
and that death occurred, on the date stated above, at
89 m.
The CAUSE OF DEATH was as follows:
Deterus
(duration)
yrs ..
3
.ds.
mos.
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 ?. Fred Ellamer
(Signed).
. M.D.
(Address)
Minh Chilcapital
Date
·ful;
(Month)
(Day)
19 21
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
(Umty Ty)
(City or town)
20 UNDERTAKER
ADDRESS
324 market
Permit
position
Date of issue of permit 7/87/21
DATE OF BURIAL July 9.1921 Śniry,
131
(helin ford (City or /Yown)
Registered No 46
City or"
Slidesfond No:
Teede
4
.(If in the Army or Nav'y of the United States, give rank, organization, ctc.)
fifth Chelich finds
Ward.
(If non-resident give city or town and Statc)
MARGIN RESERVED FOR BINDING
6-'20. 20,000.
No.
, 1921.
10 NAME OF
FATHER
f. Reedy
Ready Hother
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, etc. Women at home, who are engaged in the duties of the house- hold only (not paid Housekeepers who reccive 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; 4 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 tause 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
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.
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 tho 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, Sees. 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 dietl; .. . . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . '. a satisfactory written statement con- taining the facts required by law to be returned and recorded, which .. . shall be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in lieu thereof a certifi- cate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician, If death is caused by violence, the medical examiner only shall make such certificate. . ... The person to whom the per- mit is so given and the physician who certifies to the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise a description of such person as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are supposed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
12
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 unrclated 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.
S
(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
MARGIN RESERVED FOR BINDING
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See 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. should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH County. Middlea
Maxo State
City or Town.
Chiquisford
„No.
Cast
Cheles ford
(If death occurred in a hospital or institution, givc its AAME instead of street and number)
alice Rita MC Multe
2 FULL NAME
(a) Residence. No.
( Usual place of abode)
Length of resideoce in city or town where death occurred
years
months
days.
How loog 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) Vingle
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH March
7 AGE
Years
6
Months
4
Days 6
If LESS thao 1 day, ........ hrs. or ........ min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED (a) Trade, professioo, or particular kind of work. (b) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
Senge A Mi Kulti
11 BIRTHPLACE OF FATHER (City) (State or country)
Chelen ford
maso
12 MAIDEN NAME
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