USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 52
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If investigation shows the death to have been due to dis- ease, specify: (1) Under cause, its known or presumable nature; and (2) under manner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous, of the brain (basal ganglia) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
DESCRIPTION (for unknown person)
NOTICE TO UNDERTAKERS : No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have come to his death by violence, until a permit in writing, signed by the Medical Examiner, has first been obtained. - Revised Laws, Chap. 24, Sec. 20.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
FOR
FORM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
148
1 PLACE OF DEATH
County
Midex
State.
mark.
(City or Town)
City or Town
Chelmsford
No ..
North Road
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Emma Elizabette Hubbard
(a) Residence. No ..
north Road
St.,
.....
.Ward.
( Usual place of abode)
Length of residence in city or town where death occurred
years
mooths
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH Sept
(Month)
(Day)
(Year)
Years
Months
1
Days
12
If STILLBORN, eoter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
at home
9 BIRTHPLACE (City)
Lowvele
(State or country)
man
10 NAME OF
FATHER
Charles Hubbard
11 BIRTHPLACE OF
FATHER (City ).
Telle
(State or country)
maine
12 MAIDEN NAME
OF MOTHER
ann Jewett
13 BIRTHPLACE OF
MOTHER (City)
Byfeld
(State or country)
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
100
Date of.
Was there an autopsy ?
no
What test confirmed diagnosis ?
M. L. Aller
(Sigoed).
M.D.
(Address)
Lawell, Sears
Date
(Month)
(Day)
5
1921
(Year)
14 Myra S. Hubbard
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Lowell
Lowell
(Cemetery)
(City or town)
DATE OF BURIAL
Nov 8 1921
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
Official position
Down Clock
Date of issue
of permit 11/8/21
No
ADDRESS
Chelunford
Permit
12-'20-100.000
3 SEX - 7 AGE 67 PARENTS Informant. 15 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
MARGIN RESERVED FOR BINDING
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY, That I attended deceased from
1919
to.
death
19
that I last saw
ha
alive on
mrs 4
19.2 ...... ,
and that death occurred, on the date stated above, at ...
9 (?) a.
.... m.
The CAUSE OF DEATH was as follows:
If LESS than 1 day, ........ hrs. or ....... min. Chronic replentio
(duration) ?
.yrs.
mos.
ds.
CONTRIBUTORY
Hisonelasis popliteal andity
( SECONDARY)
(duration)
.yrs ...
mos.
ds.
(Address )
Chefmunford, north Rd.
11/8/21 Prestin h. nord
20 UNDERTAKER
Walter Parham
(If in the Army or Navy of the United States, give rank, organization, etc.)
( If non-resident give city or town and State)
1921
24
1854
Registered No
63'
.
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 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 receivo a definito 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. 4
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cere- brospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualified. is indefinite); Tuberculosis of lungs, men- inges, peritoneum, etc., Carcinoma, Sarcoma, etc., of ..... .. (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can he 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- 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.
EXTR.
FROM THE LAWS
COMMONWEALTH OF USETTS
GOVERNING TI
RETURN OF CERTIFICATE. . DEATH
A physician or registered hospital medical officer 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 tho deceased, his supposed age, the disease of which he died, defined as re- quired hy seetion one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . . .- Gen. Laws, Chap. 46, Sec. 9.
No undertaker or other person shall bury a human body .. . until ho has received a permit from the hoard of health or its agent . . . or ... from the clerk of the town where 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 containing the facts required by law to be returned and recorded, which shall he accompanied, in case of an original interment, by a satisfactory certi- fieate of the attending physician, if any, as required hy law, or in lieu thereof a certificate 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, a physi- cian who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certi- ficate. ... The person to whom the permit is so given and the physi- cian certifying 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. - Gen. Laws, Chap. 114, Sec. 45.
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died hy violence. - Gen. Laws, Chap. 38, Sec. 6.
. . . He shall in all cases certify to the town clerk or registrar in the place where the deceased died his name and residence, if known; other- wise a description as full as may he, with the cause and manner of death. -Gen. Laws, Chap. 38, Sec. 7.
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 nceded.
(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 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
MARGIN RESERVED FOR BINDING
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 instructions and extracts from the laws on back of certificate.
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH County.
Class
(City or Town)
Registered No. 6%
City or Chelmsford Sauter No. Nowtwin Road John F. The offrey
St ............... Ward (If death occurred in a hospital or fastitution, give its NAME instead of street and number)
2 FULL NAME
258 Concard
(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)
days.
How long in U. S., if of foreign hirth ?
50 years
- months
- days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR ØR RACE Male white
5 SINGLE MARRIED, WIDOWED, OR
5a If married, widowed, or divorced HUSBAND of (OH) WIFE of
6 DATE OF BIRTH
Month)
(Day)
(Year)
7 AGE Years 62
Months
Days
If LESS than 1 day ......... hrs. or ........ min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work (h) Name of employer
Petural Derland
PARENTS
11 BIRTHPLACE OF FATHER (City) (State or country)
12 MAIDEN NAME OF MOTHER
Vycland Sarah MichEmma
13 BIRTHPLACE OF MOTHER (City) (State or country)
Wieland
Date.
(Day)
1921 (Year)
14 Me. John Muldoon
Informant (Address ) 258 Concord fr.
(Cemetery)
(City pr town)
15 11/12/2 Justin L. Moore
Filed (Month) (Day) (Year)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the hurial or transit permit was issued.
led vino prestin Li More oficiale zesone Click se o 11/12/2/
Permit
.No.
.. .....
17
I HEREBY CERTIFY, That I attended deceased from not:5 19 19
21,00 nov. 11 21
that I last saw h MMM alive on
nov.11,
1921
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH was as follows : Carmona_oflevar
(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 ?
no,
Date of.
Was there an autopsy ?
no.
What test confirmed diagnosis ?
(Signed)
Antra C Ocarbonia
M.D.
(Address).
Chilenofor marsi
DATE OF BURIAL Nov.14-1921
20 UNDERTAKER
ADDRESS Jewell
6-'20. 20,000.
(a) Residence. No. ( Usual place of abode) Length of residence ia city or town where death occurred Gears months
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
11
1921
(Year)
149
9 BIRTHPLACE (City) (State or country)
10 NAME OF FATHER
REVISED UNITED STATES STA
[Approved by U. S. Census and ALL,
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 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; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (diseass 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," cto.), " Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- . mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following dissasss, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- rlage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
LAWS OF THE 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 agc, 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, Sccs. 10 and 1, as amended by Acts of 1910, Chap. 322.
No undertaker or other person shall bury a human body . . . until ho 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 the sslectmen 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 causs 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 ths clerk or registrar may require. - Revised Laws, Chap. 78, Sec. $8.
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 thoso of persona found dead.
Form R-305
The Commonwealth of Massachusetts
MEDICAL EXAMINER'S CERTIFICATE. OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
(ISSUED UNDER THE PROVISIONS OF REVISED LAWS, CHAPTERS 24 AND 29)
County
middlesex
State
Registered No ...
12.67
(Place of death)
(Place of residence)
City or Town ...
howell
......
(If death occurred in a hospital or institution, give its NAME Instead of street and number)
2 FULL NAME
(a) Residence.
No.
Woodbine
(If in the Army or Navy of the United States, give rank, organization, etc.) Ohelmotas St., .. Ward
(If non-resident give city or town and State)
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
days
How long in U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
m.
4 COLOR OR RACE
w.
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
march 17, 903
(Month)
(Day)
(Year)
7 AGE
18
Years
Months 5
Days
If LESS than
I day ......... brs.
or ........ min.
8 OCCUPATION OF DECEASED for auto mechanic
(a) Trade, profession, particular kind of work (b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
howell
9 BIRTHPLACE (City) .
(State or country)
10 NAME OF
Francia Po.
11 BIRTHPLACE OF FATHER (City) howell
(State or country) masa.
12 MAIDEN NAME OF MOTHER
rebekaha number
BIRTH MOTHER (City) Cannot be learned (State or country Canada
14 Father
Informant .. (Address) Chelmsford man.
15 4
Filed hool4 1921
Registrar of city or town where death occurred Filed /4/15/21 Juintice (por)
(Month) Registrar of tity of town Where de camed resided
17. I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof Staun Wounds of Thigh and abdomen accidental hooded qun discharged in being used to youndig on tree trunk with butt.
(See reverse side for additional space)
Whelm ford
helm
18 Where was injury sustaind
if not at place of death ?
Thomas boumith
(Signed) ...
howell
2, M.D.
(Address)
othiliati middlesexio
nov, 12, 192.
(Month)
(Day
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Edson, Lowell
(Month) (Day) (Year)
20 UNDERTAKER 4. Wittealey
ADDRESS Lowell
21 Burial permit issued by
Official position
22 Date of issue
9-'18. 10,000.
See reverse side for extracts from the laws of the Commonwealth and instructions, DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. should be carefully supplied. AGE should be stated EXACTLY. MEDICAL EXAMINERS should state CAUSE OF
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information MARGIN RESERVED FOR BINDING
150
65
Registered No ...
No: St.
St., .... Ward
Ernest S. Wickimon
ose mass
1921
(Year)
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
november 11
( Month)
(Day)
If STILLBORN, enter that fact here
PARENTS
Date
DATE OF BURIAL
nov. 14,192
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 deccascd, furnish for registration a stand- ard certificate of death, stating to the best of his knowledge and belicf 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.
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