Deaths 1920-1921, Part 57

Author: Chelmsford (Mass.)
Publication date: 1920-1921
Publisher:
Number of Pages: 316

USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 57

Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).

should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH

Fil

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

(h) Name of employer

MEDICAL CERTIFICATE OF DEATH

16 DATE OF DEATH

(Month)

Dee

myocardial Digeneration

Chelmsford man.

DATE OF BURIAL alec. 8. 21

REVEL

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, Civilengincer, 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, ete. Women at home, who are engaged in the duties of the house- hold only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should 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 tho 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 tho 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 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- 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.

RETURN OF CERTIFICATES OF DEMINI

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 licu thercof a eertifi- 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 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 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 disease unrelated to any form of injury, have dicd 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

16/ So Chelmsford, (City of Town) 76

1 PLACE OF DEATH

County.

Middlesex

State

City ox Town ..

So, Chelmsford

.No ..

Maple Ave

.Ward

(If death occurred in a hospital or institution, give its NAME instead of street and number)

2 FULL NAME

Mabel E. Page.

(If in the Army or Navy of the United States, give rank, organization, etc.)

(a) Residence. No.

( Usual place of abode)

Makele Anetil helma

St.,

Ward.

(If non-resident give eity or town and State)

Length of residence in city or town where death occurred

7 years

months

days.

How long in U. S., if of foreign hirth ?

years

months

days

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Females

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

July

( Montby

121882

(Day)

(Year)

7 AGE

Years

Months

Days

If LESS than 1 day, ........ hrs. For ....... min.

If STILLBORN, enter that fact here

8 OCCUPATION OF DECEASED

(a) Trade, profession, or

particular kind of work.

At Home,

9 BIRTHPLACE (City)

Lowell

(State or country)

Mare.

10 NAME OF

SamuelS. Pagen

11 BIRTHPLACE OF

FATHER (City) .....

Sowell

(State or country)

Maca.

12 MAIDEN NAME

OF MOTHER

Lydia H. Garlands

transmet Bartlett

13 BIRTHPLACE OF

MOTHER (City)

(State or country)

MN.

MEDICAL CERTIFICATE OF DEATH

16 DATE OF DEATH

(Month)

Decr

1921.

(Year)

(Day)

I HEREBY CERTIFY, That I attended deceased from

19%), coffee 8

, 1921

that I last saw her

alive on

1921.

and that death occurred, on the date stated above, at ..

11.55P

„m.

The CAUSE OF DEATH was as follows :

Pernicious Cences

mia

(duration)

2 yrs

.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 ?

200

Date of

Was there an autopsy ?

200

What test confirmed diagnosis ?.

m. D Burns.

, M.D.

(Signed) ....

(Address) ..

force man

Dec,

1921

Date.

( Month)

(Day)

Year)

Informant

Mara Halter J. Billa

(Address)

In Chelmsford, Masa.

15 2/10/21 factice h. nood

Fil (Month) (Day) (Year)

REGISTRAR

21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me Feechce h. 200 BEFORE the hurial or transit permit was issued

Official :. position

Poure dechisue

of permit 12/10/21

Permit

DATE OF BURIAL

Dec. 11,1921.

(Cemetery)

(City or town)

20 UNDERTAKER

KgromaHealey.

ADDRESS

Sowell Mars

.No ...

1921. 39- 1882

MARGIN RESERVED FOR BINDING

FATHER PARENTS 14 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

6-'20. 20,000.

19 PLACE OF BURIAL, CREMATION, OR REMOVAL

Edcom

Lowell Mace

Registered No.

REVISED UNITED STATES STAND, SE OF DEATH

[Approved by U. S. Census and Amera. ......____ association]

Am Bryant.

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. 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 "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 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 (retired, 6 yrs.). For persons who have no occupation whatever, write None.

... (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 (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital," "Senile," etc. )."Dropsv.""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- l'ERAL 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.

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 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, 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 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.

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.

FORM R-301

OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS

The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH Chelmsford

162

(City or Town)

1 PLACE OF DEATH

County

idilesex

State Lass ..

Registered No. 77

City or Town

Chelmsford

No ...

997 Princeton St.

St.

Ward

(If death occurred in a hospital or institution, give its NAME instead of street and number)

2 FULL NAME

William Qualters

(If in the Army or Navy of the United States, give rank, organization, etc.)

(a) Residence. No.

907 Princeton St.

St.,

Ward.

(If non-resident give city or town and State)

( Usual place of abode)

Length of residence ia city or town wbere death occorred

years

mootbs

days.

How long io U. S., if of foreign birth ? I

years

mooths

days

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Tale

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 - ( Month)

(Day)

(Year)

7 AGE

Years

Months

Days

If LESS thao 1 day, ........ b:s. or ........ min.

If STILLBORN, eoter that fact bere

8 OCCUPATION OF DECEASED

(a) Trade, profession, or

particular kind of work

Creative

(b) Name of employer

Silesia Vill

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 ?. Fuel Waney

(Sigoed)

(Address ).

Date. Dee 10 1921

( Month)

(Day)

(Year)

19 PLACE OF BURIAL, CREMATION, OR REMOVAL

St. Patrick's Lo·ell

DATE OF BURIAL Tec. 13 1921

(Cemetery)

(City or town)

20 UNDERTAKER/

ADDRESS

Quel Sif Downey Son 324 Marsat &t

0 Official were check position

of 12/04/2/ -Date of issoe of permit

Permit

21 I HEREBY CERTIFY that a satisfactory stao- dard certificate of death was filed with me BEFORE the burial or transit permit was issoed

ih me Justin h. Moore

MEDICAL CERTIFICATE OF DEATH

16 DATE OF DEATH

(Month)

(Day)

(Year)

I HEREBY CERTIFY, That I attended deceased from

nor 10

Dee10

that I last saw h

alive on

Dee 9

19.

21.

and that death occurred, on the date stated above, at

2 P m. The CAUSE OF DEATH was as follows : Chronic Endo cardiles

(duration)

yrs ..........

mos.

ds.

9 BIRTHPLACE (City)

(State or country)

Ireland

10 NAME OF

FATHER

John Qualters

11 BIRTHPLACE OF

FATHER (City)

(State or country)

Ireland

12 MAIDEN NAME

OF MOTHER

Catherine Jordan

13 BIRTHPLACE OF MOTHER (City) (State or country) Ireland

Informant.

Mrs. Fary Curran, Sister

(Address) 997 Princeton St.

15 17/12/201 Justice Lithoou

File (Month) (Day) (Year)

REGISTRAR

6-'20. 20,000.

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

MARGIN RESERVED FOR BINDING

PARENTS

I86 3

Dec

1921

M.D.

REVISED UNITED STATES STANDARD CEN SCALE OF UL.

[Approved by U. S. Census and American Public H- 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 occupations a single word or term on tho first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Locomotive engineer, Civil engineer, 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 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 receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should bo taken to report spe- cifically the occupations of persons engaged in domestic 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, 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,""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.

Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.

Deaths 1920-1921, Part 57

Author: Chelmsford (Mass.) Publication date: 1920-1921 Publisher: Number of Pages: 316

Author: Chelmsford (Mass.)
Publication date: 1920-1921
Publisher:
Number of Pages: 316