USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 47
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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, childhirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, moningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
RETURN OF CERTIFICATES OF DEMIN
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 helief 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 hy 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 he 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 certificato. . .. 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 he obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Reviscd 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 he, 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 disahled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is ahsent 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 hy the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following ahortion, 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
135
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
edd less
City or Town
Shelucio ford
No.
... State
Cast Cheluiford
St ...
Ward
(If death occurred in a hospital or institution, giveAts NAME instead of street and number)
2 FULL NAME
Stell Down
East Cheluns ford
St.,
Ward.
(If non-resident give eity or town and State)
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
Mali
4 COLOR OR RACE
Muti
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) Vingt
5a If married, widowed, or divorced .
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
( Month)
(Day)
7 AGE
Years
Months
Days
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation
... mos.
If LESS than 1 day ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work (b) Generai nature of industry, husiness, or establishment in which employed ( or employer) (c) Name of employer
Shelia Ford
9 BIRTHPLACE (City) (State or country)
maso
10 NAME OF
FATHER
Peter & Maria
11 BIRTHPLACE OF FATHER (City) .. (State or country)
Quand
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (City) (State or country)
Queland
14 Peter & Clair other Informant
(Address ) Easy #chilin ford
15
(Month) (Day) (Year)
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with Letter . I heard BEFORE the hurial or transit permit was issued.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
ana
8
(Month)
(Day)
1921
(Year)
17 I HEREBY CERTIFY, That I attended deceased from
19
to ...
Gug 8
, 19 2%
that I last saw h .......
.. alive on
sweetun
19.
,
and that death occurred, on the date stated above, at
6.36 9.m.
The CAUSE OF DEATH was as follows :
Still born
(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 EVarney
M.D.
( Address).
North ChelunEng
Date
( Month)
8-19/21
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, CR REMOVAL It Jating Countries
DATE OF BURIAL Dug9 1921
(Cemetery)
(ny'or town)
20 UNDERTAKER
ADDRESS
2324 Marca
cial Vorone Click position.
Date of issne of permit./ .. 08/9/2/
Permit
1-6-'19. 150,000.
MARGIN RESERVED FOR BINDING
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 N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information PARENTS
STANDARD CERTIFICATE OF DEATH
Registered No.
50
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
( Usual place of abode)
F
195 KYear)
Qua 9 1921 Juin Durch Laury REGISTRAR
No
Approved Dy V. J. UCaSua BU .. we UN
JSETTS
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 he sufficient, e. g., Farmer or Plonter, Physicion, Compositor, Architect, Locomotive engineer, Civilengineer, Stationary fircman, ctc. But in many cases, especially in industrial employments, it is necessary to know (o) 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) Salcsman, (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 Doy laborer, Form laborer, Loborer - Cool mine, etc. Women at home, who are engaged in the duties of the house- hold only (not paid Housekcepers 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 Servont, Cook, Housemoid, ctc. 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: Former (retired, 6 yrs.). For persons who have no oceupation 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; Bronchopneumonio ("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); Meosles; Whooping cough; Chronic valvulor heort discase; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Meosles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, suclı as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old agc," "Shock," "Uremia,""Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all discases 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.
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 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, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . .. - Revised Laws, Chop. 29, Secs. 10 and 1, as amended by Acts of 1910, Chop. 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 Lows, 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 Lows, Chop. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the ohservance 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 investigato 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
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 (b) Name of employer
The Commamuralth of Massachusetts
STANDARD CERTIFICATE
OF DEATH
136 No Breledare (City or Town)
51 Registered No. 6673
St., .Ward (If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
(a) Residence.
No.
(Usual place of abode)
Length of resideoce in city or town where death occorred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
12 1921 (Year)
17
I HEREBY CERTIFY, That I attended deceased from
192 12 , to. 1921 .
that I last saw her alive on 12 192. and that death occurred, on the date stated above, at IDA m. The CAUSE OF DEATH was as follows : Myocarditis
( 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). Frank & Avec
M.D.
20 checre Fred 3
Date
ang
12 1421
(month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
......
(Cemetery)
(City or town)
20 UNDERTAKER
ADDRESS
Permit
6-'20. 20,000.
4 COLOR OR 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
7 AGE Years 7475
Months
Days
If LESS than 1 day, ........ hrs.
or ....... mio.
If STILLBORN, eoter that fact here
8 OCCUPATION OF DECEASED (a) Trade, professioo, or particular kind of work. mell Dirctive.
9 BIRTHPLACE (City)
(State or country)
England
10 NAME OF
FATHER
Poben Carson
11 BIRTHPLACE OF FATHER (City). (State or country)
12 MAIDEN NAME
OF MOTHER
Marel Vanes
13 BIRTHPLACE OF MOTHER (City) (State or country).
14 Am Band
Tro Cheentend
15 Queg 121921 Justin RiMoore Filed .. (Month) (Day) (Year) / REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stan- dard ( certificate of death was filed with mexd BEFORE the burial or traosit permit was issued
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH County imagenx
State
City or Town
No Etulianas No
Camer Haviam
(If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward.
(If non-resident give city or town and State)
16 DATE OF DEATH. (Mouth)
(Day)
Dvabella Harmon Duty 25 1577 (Day) ( (Month) (Year)
-
Official Vocon Elce position. 8/12/21 Date of issoe of permit.
No .....
Statement of occupation. - Precise statement of oceupation is very important, so that the relative healthfulness of various pursuits ean 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, ete. 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 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 specifieation, 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 entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should bo taken to report spe- cifically the occupations of persons engaged in domestic serviee for wages, as Servant, Cook, Housemaid, etc. If tho 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 "Epidemie 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, ete., Carcinoma, Sarcoma, ete., of ... ... (name origin; "Caneer" 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," ete., when a definite disease can be aseertained as the cause. Always qualify all diseases resulting from childbirth or misearriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of causo of death approved by Com- mittee on Nomenelature 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 elassified under the international elassification of causes of death], where contractcd, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1. as amended by Acts of 1910, Chap. 322.
No undertaker or other person shall bury a human body . . . until he has received a permit from the board of health or its agent, . . . or .. . from the elerk of the eity 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 ean 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, Scc. 38.
Medical examiners shall, in all cases, certify to the city or town elerk or to the eity 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, Chup. 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 ecrtify 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 sueh 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 certificato of death is needed.
(3) Medical examiners will investigate and certify to all deaths sup- posably due to injury. These include not only deaths eaused 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 persona found dead.
·
FORM R-301
MARGIN RESERVED FOR BINDING
3 SEX female 7 AGE 60 10 NAME OF FATHER PARENTS 14 Filed. N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information instructions and extracts from the laws on back of certificate. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH (b) Name of employer
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