USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 5
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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, peritoncum, 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, ctc. 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," "Ancmia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions," "Dcbility" ("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 childhirth 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 hy Com- mittec 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, meningitis, miscar- riage, nocrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
"XTRACTS
JE LAWS OF THE
MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and helief the name of the deceased, his supposed agc, the disease of which he died [defined so that it can be classificd under the international classification of causes of death], where contractcd, 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 be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in licu 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 tho 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 tho 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. - 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 deccascd 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 hodies 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 hedside 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 discase 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 hy the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following ahortion, hut also deaths frem 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
1 PLACE OF I 3 SEX F. 6 DATE OF BIRTH. particolar kind of work (h) General 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 11 BIRTHPLACE OF FATHER (City) (State or country) 12 MAIDEN NAME OF MOTHER 13 BIRTHPLACE OF PARENTS MOTHER (City). (State or country) Informant. (Address) 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 If STILLBORN, enter that fact here
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
County
DEMiddleof
State
Mars
Registered No.
1673
City or Town
East Chelmsford
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Minia J. C. P. Drowne
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
3
months
St.
Ward.
(If non-resident give city or town and State)
days.
Ilow long in U. S., if of foreign birth ?
years
mooths
days
MEDICAL CERTIFICATE OF DEATH
Pub 15-1920 (Day)
(Year)
17 I HEREBY CERTIFY, That I attended deceased from Sub 8 1920, to Get/4 ,19 29,
that I last saw her.
... alive on
Get/4
, 19_2.0,
and that death occurred, on the date stated above, at
9.30R m, The CAUSE OF DEATH was as follows :
Cagln Remilegia
(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 ?
No
What test confirmed diagnosis ?
(Signed)
archives Scobarca
., M.D.
( Address ) ..
Chelmsford man
19 1920
Date
(Month)
(Day)
(Year)
DATE OF BURIAL
Feb2 01. 20
15 Feb 18, 1920 Edward S. Rolling
Filed (Month) (Day) (Year)
REGISTRAR
21 1 HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued Edward . Rotting Official position
Down Clock
Date of issue of permit Feb. 19, 1920 No
Permit
1-6-'19. 150,000.
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVOKTED, (write the word)
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
augustus led around 16 1841
(Month)
(Day)
(Year)
7 AGE 78 Years 3 Months 9 Days
If STILLBORN, state period of uterogestation .. mos.
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or at Home
Bestim
SamuelQuiest
res
Nothingto
Julia a Sanborn
Cakestu ANI.
14 Dally de. Drie
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Lee
(Cemetery) (City or town)
20 UNDERTAKER
Dr. Herbert Blake
ADDRESS 33 Percent
23
St. Ward
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH.
(Month)
STATES STANDARD CERTIFICATE OF DEATH
by U. S. Census and American Public Health Association]
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 oceupations 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 eases, 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," 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 Housekcepers 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 domestie service for wages, as Servant, Cook, Housemaid, ete. 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 person's 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 tho 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, etc., of ... .. (name origin; "Cancer" is less definito; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (secondary or inter- eurrent) affeetion need not be stated unless important. Example: Measles (disease eausing 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," ete.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," 1 ete., 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.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or otlier authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deccased, his supposed age, the discase of which he died [defined so that it can bo elassified under the international elassification 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 licu thereof a certifi- eate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. ... The person to whom the per- mit is so given and the physician who certifies to the eauso 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. 2 .
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 eause 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 observanee 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 eare during a last illness from discase unrelated to any form of injury.
(2) Board of Health Physicians will eertify 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 attendanco or whose physician is absent from homo when the certificate of death is needed.
(3) Medical examiners will investigate and eertify 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 elcetrical 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
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
1-6-'19. 150,000,
The Commonwealth of Massachusetts
24
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
middlesex
7. State.
Mais
Registered No 13
City or Town ....
thelunsford
No.
Larlille Road
St ...
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Hubert Le. Bubed
(a) Residence.
No
Carlile Road
St.,
Ward.
(If non-resident give city or town and State)
Length of residence in city or town where death occorred
FU years
months
days.
How loog in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Mary a. Golden
6 DATE OF BIRTH
aug.
10
1862
7 AGE 57 Years 6 Months 9
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
Farmer
particular kind of work (b) Generai nature of iodnstry, business, or establishment in which employed (or employer)
(c) Name of employer
CONTRIBUTORY.
(SECONDARY)
(duration)
yrs
mos ....
......
ds.
18 Where was disease contracted
if not at place of death?
x
Did an operation precede death ?.
X
Date of.
X
Was there an autopsy ?
110.
X
What test confirmed diagnosis ?.
(Signed)
Amasa toward.
.... , N.D.
(Address).
Chelmsford Man.
20
1920.
(Year)
( Month)
(Day)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
St. Patricks Leowell
(Cemetery)
DATE OF BURIAL
(City or town)
efeb. 22 1920
15 Fel 21, 1920 Ederand Robbins Filed (Month) (Day) (Year) REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stan- S
dard certificate of death was filed with me i or transit Edward Rothen
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Web. 1900.
(Month)
1900
(Day)
1920(Year)
17
I HEREBY CERTIFY, That I attended deceased from
Feb. 8
19.20
Feb. 1900
19.24
to.
that I last saw him alive on
Fb. 19€
1920,
and that death occurred, on the date stated above, at
6.30P
m.
The CAUSE OF DEATH was as follows :
Double Broncho - Inenfranca
(duration)
.. yrs
mos ...
11
.ds.
9 BIRTHPLACE (City)
Mason
(State or country)
Maine
PARENTS
10 NAME OF
LEander Bisbee
FATHER
11 BIRTHPLACE OF
FATHER (City).
Fryburg
(State or conntry)
mel.
12 MAIDEN NAME
OF MOTHER
Sarah Way
13 BIRTHPLACE OF
MOTHER (City) fryburg
(State or country)
me
Date
20 UNDERTAKER ADDRESS James W. MYTerna Howell Mars
Torm Clack Official . position.
Date of issne of permit Feb. 21, 4 %. Permit
( Month)
(Day)
(Year)
Days
MARGIN RESERVED FOR BINDING
14 May May a Besbre Informant.
(Address) Carlisle Rd Chelmsford
STANDARD CERTIFICATE OF DEATH
(If in the Army or Navy of the United States, give rank, organization, etc.)
( Usual place of abodey
REVISED UNITED STATES STANDARD CERTA.
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can he 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 needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Lahorer," "Foreman," "Manager," "Dealer," etc., without mere precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, eto. Women at home, who are engaged in the duties of the house- held only (not paid Housekeepers who receivo a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At honte." 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 accented 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" (mcrely 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 childhirth 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.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a 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.
1
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 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 he 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.
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