USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 58
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FROM THE LAWS OF THE COMMONWEALTH OF MASSA GOVERNING THE ' RETURN OF CERTIFICATES C. 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 dato 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 tho 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 sufficiont 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 employod 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. 88.
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 nsme 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, tho 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 DEATH
County.
State
Registered No.
278
City or Town
No.
St ... Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Tu zuúcty Tottermatori
Golden have had (If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
ycars
9
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Tural
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH Nav6-1907
(Month)
(Day)
(Year)
7 AGE
Years
Months
Days
5
I day, ........ hars. or ....... min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work (h) Name of employer
Buchark
(duration)
yrs ..
mos.
4
ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death ?
no.
Was there an autopsy ? no.
What test confirmed diagnosis ?
Auchunit, Scalania
(Signed).
M.D.
(Address)
Chalanford mars,
Date.
The. 120 1921,
(Month)
(Day)
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL Ice.
Informant
(Address)
(City or town)
20 UNDERTAKER
ADDRESS
15 File 12/12/21 Julice 2. Ihoard (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
Song Justice R. Mulnon Official Pose Check out 1/12/21
Permit
No
.. m.
Mongolian Type of lives
7 to 8.
.. (duration)
.yrs.
.........
mos ....
ds.
9 BIRTHPLACE (City)
(State or country)
Oreland
10 NAME OF
FATHER
Haugh@orteringtone
PARENTS
11 BIRTHPLACE OF FATHER (City) (State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Euma Facteur
13 BIRTHPLACE OF MOTHER (City) (State or country)
Ireland
MEDICAL.CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY, That I attended deceased from Dec, 8 , 19.
2/, to. Dea /1, 19. 21
that I last saw h
er
alive on
arc. 11
, 19 ..
21
and that death occurred, on the date stated above, at ..
If LESS than The CAUSE OF DEATH was as follows: Influenza
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. 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
6-'20. 20,000.
The Commonwealth of Massachusetts
16.3
(City or Town)
2 FULL NAME
.St.,
.. Ward.
(If non-resident give city or town and State)
14
1
CONTRIBUTORY
(SECONDARY)
Date of.
14
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, irrespectivo of ago. 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, cte. Butin many eases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the sccond statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ete. 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 domestie servico for wages, as Servant, Cook, Housemaid, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, stato occupation at beginning of illness. If retired from business, that faet 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 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, etc., Carcinoma, Sarcoma, etc., of ... .. (name origin; "Canecr" 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) affeetion need not be stated unless important. Example: Measles (discase causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," cte.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," ctc., when a definite disease ean 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 eause 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.
RETURN OF CERTIFICAIGS
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 diseaso of which he died [defined so that it can be classified under the international elassification of eauses 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 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 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 elerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the eity or town elerk or to the city registrar in the place where tho 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 eare 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 eaused 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
1 PLACE OF DEATH
County.
City or Town
no chelmsford
No.
(If death oeeurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Auchaniste Champagne
(If in the Army/or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
4 amberas
(Usnal place of abode)
3 years
mooths
days. How long io U. S., if of foreign birth? 30 years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
221
4 COLOR OR RACE
W.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
marreid
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Marie Leblane
17
I HEREBY CERTIFY, That I attended deceased from
Janua
1927, to
Dec-14
1921
alive on
abril Dee 3 -
, 19 2%.
and that death occurred, on the date stated above, at 89 m. The CAUSE OF DEATH was as follows :
Organic balaton deseas y
(duration)
.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)
Dec 14 1971
Date
(Month)
(Day)
(Year)
14
Informant.
Wir Eucharcole Champagne Joseph's Chelmsford
(Address)
4 amherst
15
Filed 12/14/91 Juilin L. Moore
(Month) (Day) (Year))
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Month)
(Day)
(Year)
6 DATE OF BIRTH
( Month)
(Day)
(Year)
7 AGE 72 Years 10 Months
2 Days
If LESS thao 1 day, ........ hrs. or ....... min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
UN Homme
particular kind of work.
(h) Name of employer
In Stanislas
9 BIRTHPLACE (City) (State or country) 1.2.
10 NAME OF
Français Champagne
FATHER
11 BIRTHPLACE OF
SV Stanislas Q.S
P. 2
FATHER (City).
(State or country)
12 MAIDEN NAMECY
OF MOTHER
Eliza Lapointe
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Su Stancelas
6-2
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL De e 15-21
(Cemetery)
(City or town)
20 UNDERTAKER 9 celler
ADDRESS
17/ acker
jal Uron Click .. position
„Date of of permit 12/14/218
Permit
21 I HEREBY CERTIFY that a satisfactory stan- BEFORE the burial or transit permit was issued
12-'20-100,000
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information MARGIN RESERVED FOR BINDING
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
The Commonwealth of Massachusetts
164
STANDARD CERTIFICATE OF DEATH
(City or Town)
State. mae.
Registered No.
St., Ward
St.,
Ward.
(If non-resident give eity or town and State)
Length of residence in city or towo where death occurred
Wee.
14-1951
Fel
that I last saw h
12 -1849
PARENTS
M.D.
REVISED UNITED STATES STANDARD CERTIFICAI
[Approved by U. S. Census and American P. t.lic Health Association)
4
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. 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.
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," "Ancmia" (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.
1
5
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.
-
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 undertakeror 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 as re- quired by section one, where samc 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 hury a human hody . . . until he has received a permit from the board 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 be accompanied, in case of an original interment, by a satisfactory certi- ficate of the attending physician, if any, as required by 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 by 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 be, with the causc and manner of death. - Gen. Laws, Chap. 38, Scc. 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 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
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. 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
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
Indellerer
State.
Registered No. 80
St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Ervice W Swett
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No.
( Usual place of abode)
Length of residence in city or town wbere death occurred
69
years
months
days.
How long in U. S., if of foreign birth ?
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