USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 46
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OF MOTHER
Ellenet Roufg
13 BIRTHPLACE OF MOTHER (City) (State or country)
Marx
14 George &, MC Fully Father Informan (Address) Theles ford Mas
15 July 21 1921 fettine 2. Moon Filed:
(Monthy (Day) (Year)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stao- dard certificate of death was filed with myfeettin Encore BEFORE the borial or transit permit was issued
position
ial Voor Check
Date of issoe of permit.
of July 21/21
Permit
DATE OF BURIAL July 20.192
(Cemetery)
(City or town)
20 UNDERTAKER
V 1521
Date.
( Month)-
(Day)
(Year)
........ mos .. 6 .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).
.. (duration)
ds.
CONTRIBUTORY
(SECONDARY)
(duration) yrs ..
19
2/
16 DATE OF DEATH
Month)
(Day)
(Year)
17 I HEREBY CERTIFY, That I attended deceased from co .. 19 July 10 1921
that I last saw h
alive on
192 /
and that death occurred, on the date stated above, at
10 P m. The CAUSE OF DEATH was as follows: Q. the theme
1.32
(City or Town)
Registered No.
47
St.,.
Ward
(If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward.
(If non-resident give city or town and Statc)
MEDICAL CERTIFICATE OF DEATH
(Month)
13 /9/5 (Day) (Year)
Cast Cheles And
mass
PARENTS
6-'20. 20,000.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
JA Jatur.
ADDRESS 1324 margaret
No ..
East Chelmsford
REV J UNITED STATES
[Approved by U. S. Census and American
RETTS
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, 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," "Forcman," "Manager," "Dealer," ctc., without more precis 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 discase. 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 contributery (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," "Shoek," "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.
Stato 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, erysipolas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
RETUI .. .
VI HLATH
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.
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. 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 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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
State many
Registered No.
48
City or Town
St., ............ .Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
....
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
( Usual place of abode)
Length of residence in city or town where death occurred
years
.St.
. Ward.
(If non-resident give eity or town and State)
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
scale
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH
( Montli)
(Day)
(Year)
7 AGE
Years
If STILLBORN, enter that fact here
Months
Days
Still born
If LESS than
1 day, ........ hrs.
If STILLBORN, state period of uterogestation. ::. mos.
8 OCCUPATION OF DECEASED (2) Trade, profession, or particular kind of work. (h) Generai nature of industry, business, or establishment in which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (City) ( State or country)
10 NAME OF
FATHER
Leray P. Lakin
11 BIRTHPLACE OF FATHER (City) (State or country)
chelicafard
PARENTS
12 MAIDEN NAME
OF MOTHER
Belle R. Azwarthe
13 BIRTHPLACE OF Whatley Ofcare MOTHER (City) (State or country) Prince Edward Island Da
( Month)
(Day) (Year)
14 Leray P hakkin
Informant
(Address) Pho, Cheecunfred We
15 Qua 5, 1921 Jutting Romeoou
(Month) (Day) (Year)
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
Sur Leitin I. Moore
Official position.
Prou check!
Date of issoe of permit
" aug 5/21
DATE OF BURIAL alex 5 1921
(Cemetery) (City or town)
20 UNDERTAKER
ADDRESS
Permit
1-6-'19. 150,000.
MEDICAL CERTIFICATE OF DEATH
ang
(Day)
1921 (Year)
17 I HEREBY CERTIFY, That I attended deceased from
19
, to
19
that I last saw h
alive on
19
and that death occurred, on the date stated above, at
The CAUSE OF DEATH was as follows :
... min. Premature Binck
1/2 horas.
(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) Fred
M.D.
(Address ).
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Giverride
4-
1921
MARGIN RESERVED FOR BINDING
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information instructions and extracts from the laws on back of certificate. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
133 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH CO County
months
16 DATE OF DEATH.
(Month)
8.30 Pm
No.
CHUSETTS
GOVERNING THE
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 fircman, 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 necded. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ete. Women at home, who are engaged in the dutics 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 discasc. 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 necd 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," ctc.), "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 causc of death approved by Com- mittee on Nomenclature of the American Medical Association.) .
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Reviscd 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 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 Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Middlesex
State
Mass
Registered No.
St., .Ward
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
Dorothy. H Grease
(If in the Army or Navy of the United States, give rauk, organization, etc.)
(a) Residence.
Notar Har fuldt adame
St.,
Ward.
( Usual place of abode)
Length of residence in city or town where death occurred Life years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single.
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH
(Month)
2,7 (Day)
1921 ( Year)
7 AGE Years
Months
Days
If LESS than I day, ........ hrs. or ........ min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work.
9 BIRTHPLACE (City)
North Chelow fod
(State or country)
10 NAME OF
FATHER
albert 6. 6 rease
11 BIRTHPLACE OF
FATHER (City) ...
Providence.
(State or country)
R.J.
12 MAIDEN NAME.
OF MOTHER
Allan aquant V. Ridley.
13 BIRTHPLACE OF
MOTHER (City)
Scotland.
(State or country)
14 albat & brace
15 Sug 7 1921 Justin 4. 200
Filed (Month) (Day) (Year) //
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 frectie L. Micorue Official
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Paraside
(Cemetery)
Yate Clube Jook Que 7th 1921,
(City or towny
DATE OF BURIAL
20 UNDERTAKER ADDRESS William H. Saunder MIT APPLETON ?
Freon Eluk
Date of issue of permit.
Gug 7/21
Permit No
6-'20. 20,000.
MARGIN RESERVED FOR BINDING
3 SEX PARENTS Informant. (Address) N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information instructions and extracts from the laws on back of certificate. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH (h) Name of employer
-
134
North & heloma fond. (City or Town) 49
City or Town
Worth Ctulunstad
No.
(If non-resident give city or town aud State)
16 DATE OF DEATH August
(Month)
(Day)
1921.
(Year)
17 I HEREBY CERTIFY, That I attended deceased from 27 1921 to
1921
that I last saw her
alive on
6
1921
02.
and that death occurred, on the date stated above, at
12 20 P
m.
The CAUSE OF DEATH was as follows:
Meningitis
.
(duration)
.. yrs ..
.........
mos ...
.ds.
CONTRIBUTORY.
(SECONDARY)
(duration) ........... .. mos .. ...... .ds. .. yrs ...
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).
Franck 2 Placein.
M.D.
(Address) Oto Checms Inc
6
1921
Date
( Month)
(Day)
( Year)
position
MEDICAL CERTIFICATE OF DEATH
6
Female White.
9
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. 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 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 cercbrospinal 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 he 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,""Dehility" ("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 childhirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
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