USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 56
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Medieal examiners shall, in all eases, eertify to the eity or town elerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise a deseription 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 sueh persons as are supposed to have come to their death by violenee. - 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 praetiee:
(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 medieal 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 inelude not only deaths caused directly or indirectly by traumatism (ineluding resulting septicemia), and by the aetion of chemical (drugs or poisons), thermal, or clectrical 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
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Chelmsford (City or Town) 3 3
1 PLACE OF DEATH
County ..
Middlesex
State. Mass ..
Registered No.
St ..... Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Martha Cahey.
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No ...
Chelmsford
St.,
Ward.
(If non-resident give city or town and State)
(Usual place of abode)
Length of resideoce in city or towo where death occurred
1 4 years
months
days.
How loog io U. S., if of foreign hirtb ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH ..
Meg 5 1921
(Month)
(Day)
(Year)
5a If married, widowed, or divorced
HUSBAND of
John Cahey
(or) WIFE of
6 DATE OF BIRTH
Not Known
( Month)
(Day)
(Year)
If LESS thao
1 day, ........ hrs.
or ........ min.
If STILLBORN, eoter that fact bere
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work ..
At Home
9 BIRTHPLACE (City)
(State or country)
Ireland
10 NAME OF
FATHER
John Best
11 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Mary Overon
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
Date of ..
Was there an autopsy ?
Lab,
What test confirmed diagnosis ?
(Signed)
Hin. JEwelt
M.D.
(Address).
2 de Central R
Date.
Rua .
5
(Month)
(Day)
1921
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Edson
Lowell
DATE OF BURIAL
Des 7 21
(Address)
Chelmsford
(Cemetery)
(City or town)
20 UNDERTAKER
ADDRESS
Lowell
15 12/5/21 Julice h. Kcook W. Herbert Blake
(Month) (Day) (Year)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stao- dard certificate of death was filed with me BEFORE the burial or traosit permit was issued
De Justice Rullar Official Tocore Checkis
Date of of permit Dee, 5/2%.
Permit
6-'20. 20,000.
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information MARGIN RESERVED FOR BINDING
3 SEX Female 7 AGE PARENTS 14 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 Commomuralth of Massachusetts
158
(duration) .yrs ....
mos ......
.ds.
CONTRIBUTORY
Cher. napleites
(SECONDARY)
17
I HÆREBY CERTIFY, That I attended deceased from
Saft.19
19.2
to
nov. 5
19
that I last saw h
alive on
· Www. 30
1927.
and that death occurred, on the date stated above, at
6.30 am.
The CAUSE OF DEATH was as follows : Chronic Valvular Heart
Years
92
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Wi dow
Months
Days
(duration)
............. yrs ................
mos ...
ds.
Informant
Hugh Cahey
City or Town ...
Chelmsford
No.
# 106 Columbus Ave
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Associatioo!
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, ctc. 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 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 "Laborcr," "Foreman," "Manager," "Dealcr," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of tho house- hold only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may bo 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 (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,""Senilc," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Wcakness," etc .; when a definite disease can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "PUERPERAL peritonitis," etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclaturo 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.
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 discase of which he dicd [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 scen 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 dicd; . . . 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 tho 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 cxaminers 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 diseaso 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 investigate and certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
-
FORM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Chelmsford
1 PLACE OF DEATH
County ..
Middlesex
City or Town
No. Chelmsford
No.
Middlesex
St., Ward
(If death oeeurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Elizabeth Beaudette
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
Middlesex St. No. Chelmsford
Ward.
(If non-resident give eity or town and State)
Length of residence ia city or town where death occorred
11
years
months
days.
How long ia 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)
Married
5a If married, widowed, or divorced
HUSBAND of
Alexandre Beaudette
6 DATE OF BIRTH
August 13,
(Month)
(Day)
(Year)
Years
Months
3
Days
23
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
At Home
St. Louis, P.Q.
9 BIRTHPLACE (City)
(State or country)
Canada
10 NAME OF
FATHER
Charles Vezina
11 BIRTHPLACE OF
FATHER (City)
(State or country)
Canada
Ile au Grue, P.Q.
12 MAIDEN NAME
OF MOTHER
Leonore Tourigny
13 BIRTHPLACE OF
MOTHER (City)
Ile au Grue, P.Q.
(State or country)
Canada
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec. 6th. 1921
(Month)
(Day)
(Year)
17
I HEREBY, CERTIFY, That I attended deceased from
co
Nov.29th
, 1941
Dec 6, 19.
21
that I last saw h.
alive on
1921.
and that death occurred, on the date stated above, at.
1:05 A .m. The CAUSE OF DEATH was as follows : Cerebral HermanhasS.
2ds.
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 ?
What test confirmed diagnosis ?
(Signed) James
ban M.D.
(Address).
122 Central
1921
(Month)
(Day)
(Year)
Informant ...
Alexandre Beaudette
(Address)
No. Chelmsford
(Cemetery)
(City or town)
20 UNDERTAKER Amedee Archambault
ADDRESS
Lowell
15 12/7/21
Filed (Month) (Day) (Year)
REGISTRAR
led il mi Justin h. Moon
Official position
Date of
Permit
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued
6-'20. 20,000.
MARGIN RESERVED FOR BINDING
3 SEX Female (or) WIFE of 7 AGE PARENTS 14 should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH (b) Name of employer 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 53
159
(City or Town)
State
Mass.
Registered No .. 74
(Usual place of abode)
11
of permit 12/7/21
No .......
1
Date
12
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
St. Joseph, E. Chelmsford
DATE OF BURIAL
Dec. 9,1921
1868
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[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 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 lino will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stationary fireman, ete. 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) Salcsman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Lahorer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the house- hold only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Houscwork, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifieally the oceupations of persons engaged in domestic serviee for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING NEATH, 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, ete. 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,""Scnile," 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.
COMMONWE.
GOVER
RETURN OF CERTIFICATES OF DEMIII
A physician shall forthwith, after the death of a person whom he lias 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 ean be elassified 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 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- 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 ecrtifies 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. $8.
Medical examiners shall, in all cases, certify to the eity 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 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 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 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 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 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
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
1 PLACE OF
City or Tow
Cheleads
No.
St .... Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Elizabeth S. Merrill
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No ..
(Usual place of abode)
St.,
.Ward.
(If non-resident give city or town and State)
Length of residence in city or town where death occurred
2/2 years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Seo. M. Merrill
6 DATE OF BIRTH
( Month)
NO (Day)
185
(Year)
Years
Months
4
Days
26
If LESS than
1 day, ........ brs.
or ....... min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
House paper
9 BIRTHPLACE (City)
(State or country)
Тихо
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 ? Antun 4, Scolonia
(Signed)
M.D.
(Address ) ..
Dic.
6
1921.
Date ..
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
ader
(Cemetery)
(City or tówn)
20 UNDERTAKER
ADDRESS
Saunders
217 APPLETON ST
Permit
BEFORE the burial or transit permit was issued
Official position
oron check
Date of issue of permit
12/6/2/
No ...
1921
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
21
to ...
Dac. 6
21
19
that I last saw h 21 alive on
azc 5
2/
19
and that death occurred, on the date stated above, at
5:200
The CAUSE OF DEATH was as follows : Incipient Qneumonia
(duration)
... yrs ....
mos ...
1
da.
CONTRIBUTORY.
(SECONDARY)
(duration)
.yrs
......... .mos ............... .ds.
11 BIRTHPLACE OF
FATHER (City).
England
(State or country)
12 MAIDEN NAME
OF MOTHER
Mary Lynn
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Frefand
14 Frederick Derbyshire
15
12/6.21 Juin h. more
(Month) (Day) (Year)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stan-
6-'20. 20,000.
The Commonwealth of Massachusetts
160
(City or Town)
State ...
Registered No. 75
MARGIN RESERVED FOR BINDING
County
3 SEX
7 AGE
66
10 NAME OF
FATHER
PARENTS
Informant.
(Address)
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