USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 53
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No undertaker or other person shall bury a human body ... until he has received a permit from the board of health or its agent, .. . or ... from the clerk of the city or town in which the person died; . . . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written statement containing the facts required by law to be returned and recorded, which .. . shall be accompanied by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thercof a certificate as hercinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insuffi- cicnt, 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 permit is so given and the physician who certifics to the cause of death shall thercafter furnish for registration any other necessary infor- mation 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 sup- poscd 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 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 necded.
(3) Medical Examiners will investigate and certify to all deaths supposably 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.
COPIES OF RECORDS OF DEATHS OF NON-RESIDENT DECEDENTS
The clerk of each city and town shall forthwith make certi- fied copies of the records of all . . . deaths recorded during the previous month, if the . . deceased [ was a resident] of any other city or town in this commonwealth or in any other state at the time of said . . . death, and transmit them to the clerk of the city or town of which such . . . deceascd person [was] resident at the time of the said ... death ... and the clerk of a city or town in this commonwealth so receiving such certified copics, or certificd copies of . . . deaths, from the clerk of a city or town without the commonwealth, shall record the same. - Remsed Laws, Chap. 29. Sec. 13, as amen.de.' by Acts of 1910. Chap. 93, Sec. 3.
DESCRIPTION (for unknown person)
FORM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
151 Chelmsford :ass. .... (City or Town)
Registered No. 66
St ..... ...... .Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(If in tho Army or Navy of the United States, give rank, organization, etc.)
St.,
... Ward.
(If non-resident give city or town and Statc)
Length of residence in city or town where death occurred
29
years
-
months
days.
How long in U. S., if of foreign birth ?
50
years
months
days
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Month)
November.
14
1921
(Year)
(Das)
17
I HEREBY CERTIFY, That I attended deceased from
Ich.22
192/
., to Wav. 14
1921.
that I last saw h. alive on
Un mensch. 14
1926.
and that death occurred, on the date stated above, at
11.40 Am.
The CAUSE OF DEATH was as follows :
Puhmaar Superculair
....
(duration)
. yrs ...
8
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)
(Address ). 175central
Date
(Month)
(Dar)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL St. Patrick's
LOWCII
DATE OF BURIAL NOV. 17
(Cemetery)
(City or town)
20 UNDERTAKER
15 Filed 11/16/21 Justice R.Nooch (Month) (Day) (Year) REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with monetece R. Alot BEFORE the burial or transit permit was issued
Official eposition.
Pocon élec sen Date of of permit ...
e
Permit
No ..
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH 63
MARGIN RESERVED FOR BINDING
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.
1 PLACE OF DEATH
County.
City or Town.
North Chelmsford
2 FULL NAME
Patrick J. Feady
(a) Residence.
No.
I65 Tightnan
( Usual place of abode)
3 SEX
.. ale
4 COLOR OR RACE
White
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Tary O'Hare
6 DATE OF BIRTH
(Month)
"(Day)
7 AGE
Years
Months
Days
-
If STILLBORN, enter that fact here
9 BIRTHPLACE (City)
(State or country)
Ireland
10 NAME OF
FATHER
Tamel ready
11 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Mary Herbert
13 BIRTHPLACE OF
PARENTS
MOTHER (City)
(State or country)
Ireland
14
Informant
IS. CIV LeECH Fife
(Address)
65 Tightman St.
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
(b) Name of employer
Iddiecez County
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Tarried
1855
(Year)
if LESS than
1 day, ........ hrs.
cr ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work Stationery Fireran
6-'20. 20,000.
PERSONAL AND STATISTICAL PARTICULARS
State.
ass.
No. 185 Tiol tran
ADDRESS
"_M.D.
14
/ 92/
( Year)
REVISED UNITEDS 07
CERTIFICATE OF DEAin
[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 be known. The question applies to cach and every person, irrespective of age. For many occupations a singlo word or term on tho first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stationary fireman, etc. Butin many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when ncedcd. 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 dutics of the house- hold only (not paid Housekeepers who receive a definite salary), may be entercd 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 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 diseasc. 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 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 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. 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 discase, and those of persons found dead.
FORM R-301
MARGIN RESERVED FOR BINDING
3 SEX Female 7 AGE 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 Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Staté .. Mass.
Registered No. 67
St .............. .Ward
(If death occurred in a hospital or institution, give its NAME Instead of street and number) Spenderson
(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 towo where death occurred
2
years
months
St.,.
Ward.
(If non-resident give city or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
17
I HEREBY CERTIFY, That I attended deceased from
vov 8
19
21, 0
nov 22. 19 21
that I last saw her alive on
Nov 2 2, 1921.
and that death occurred, on the date stated above, at
If LESS thao
The CAUSE OF DEATH was as follows:
1 day, ........ hrs. Endocardite.
or ....... mio. following Chorea
(duration)
yrs ... mos. 7. .. ds,
CONTRIBUTORY
(SECONDARY)
Several months
(duration)
yrs ...
mos. ds.
18 Where was disease contracted if not at place of death?
Did an operation precede death ?
200
Date of.
Was there an autopsy ?
no.
What test confirmed diagnosis ?.
(Sigoed)
Antra G. Scavona -
M.D.
(Address)
Date
nor.
23
(Monthi)
(Day)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Multawn
(Cemetery)
(City or town)
DATE OF BURIAL Med. 25,1921
ADDRESS
20 UNDERTAKER
Millian Gekundwest
Official Down clock
Date of issue of permit
Permit
21 | HEREBY CERTIFY that a satisfactory staa- dard certificate of death was filed with me BEFORE the burial or transit permit was issued is Justine h. moon
150
(City or Town)
City or Town
Arline Norman
2 FULL NAME
Chelmsford
days.
How Toog in U. S., if of foreign birth ?
years
22. 1921
(Year)
5a If married. widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
Derk. (Month)
(Day)
(Year)
Years
Months
Days
10
15
If STILLBORN, eoter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work ..
Icholas
9 BIRTHPLACE (City)
(State or country)
Masz.
10 NAME OF
FATHER
frsich ? Stendere
11 BIRTHPLACE OF
FATHER (Aty).
(State or country)
Maine
12 MAIDEN NAME
OF MOTHER
Havu d. B. Sunbae
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Canada
14 Josecity C. Henderson
Chelmsford Van
15 Filed 11/25/21 Justin Lincool (Month) (Day) (Year)
REGISTRAR
6-'20. 1.20,000.
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
12. 1906
HP
m.
Clubmotor, maso.
/ 19-21
(Year)
No ... ...
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS 1 PLACE OF DEATH/ dillas County Tulanford
No.
REVISED !?
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, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for tho 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 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 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 (retircd, 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 diseasc. 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 indefinitc); Tuberculosis of lungs, men- inges, peritoneum, etc., Carcinoma, Sarcoma, etc., of .. . (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mero 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 causc. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," ctc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittce 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 deccased, 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. 822.
No undertaker or other person shall bury a human body . . . until he has received a permit from the board of health or its agent, . . . or . . from the clerk of the city or town in which the person 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 hercinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. ... The person to whom the per- mit is so given and the physician who certifies to the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased dicd, 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
STANDARD CERTIFICATE OF DEATH
153
(City or Town)
1 PLACE OF DEATH
County ..
Middlea
State
St ...
.Ward
City or TownAllelinchia No. 1086 Chechuebad
(If death occurred in a hospital or institution, give its NAME instead of street and number) Grant
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