USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 60
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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.
FRC COMMONWEALTH
GOVERNING
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his lastillness, 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 seetion onc, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. ... - Gen. Laws, Chap. 46, Sec. 9.
No undertaker or other person shall bury a human body . .. until 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 deccascd, 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 cause and manner of death. -Gen. Laws, Chap. 38, Sec. 7.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of tho following rules of practicc:
(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 whoso physician is absent from home when the certificate of death is needed.
1
(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
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
168 OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
State
Man
Registered No.
83
City or Town
No.
.St., .. Ward
(If death oçeurred in a hospital or institution, give its NAME instead of street and number) Hunter
(If in the Army or Navy of the United States, give rank, organization, ete.)
(a) Residence.
No.
(Usual place of abode)
Length of residence in city or towu where death occurred
years
mouths
days.
How long in U. S., if of foreign birth ?
years
mouths
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Dec
(Month)
(Day)
17 I HEREBY CERTIFY, That I attended deceased from
,19
to
Dee 26
193
that I last saw h
alive on
19
and that death occurred, on the date stated above, at
69.
.... m.
The CAUSE OF DEATH was as follows :
Still Fim
(duration)
.yrs.
.mos. ds.
CONTRIBUTORY (SECONDARY)
(duration)
.yrs ...............
mos ............... ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death ?
Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
(Sigued)
Fred & Varney
M.D.
(Address).
North Chileantes
Date
Dee
26
(Month)
(Day) (Year)
19. PLACE OF BURIAL, CREMATION, OR REMOVAL querice
DATE OF BURIAL
/ (Cemetery)
(City or town)
Concertar 12/27/210
20 UNDERTAKER
ADDRESS
Fil (Month) (Day) (Year)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stau- dard certificate of death was filed with me BEFORE the burial or transit permit was issued
Official position.
Per Click
Date of issue of permit 12/27/21
Permit
1-6-'19. 150,000.
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
PARENTS
10 NAME OF
FATHER
11 BIRTHPLACE OF
FATHER (City)
(State or country)
Lacell
mass
12 MAIDEN NAME
OF MOTHER
E Janey S, Frecu
13 BIRTHPLACE OF MOTHER (City) 1 (State or country) Faca Booka
14
Informant.
(Address)
Опро, черевиквый
(Year)
7 AGE
Years
If STILLBORN, enter that fact here
Months
Days
Stilllow
If STILLBORN, state period of uterogestation .. mos.
If LESS than 1 day, ........ hrs. př ........ min.
8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work. (b) General nature of industry, business, or establishment in wbich employed (or employer)
(c) Name of employer
9 BIRTHPLACE (City)
(State or country)
man
3 SEX
4 COLOR OR RACE
Vale chito
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
( Montlı)
(Day)
(If non-resident give eity or town and State)
2 FULL NAME
St.,
Ward.
26.
1921
(Year)
MARGIN RESERVED FOR BINDING
15 12/27/21 Hurtig h. Wood
No.
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 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, Physicion, Compositor, Architect, Locomotive engineer, Civilengineer, Stationory firemon, etc. Butin many cases, especially in industrial employments, it is necessary to know (o) the kind of work and also (b) the nature of the business or industry, and thereforc an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Solesman, (b) Grocery; (a) Foreman, (b) Automobile foctory. The material worked on may form part of the second statement. Never return "Laborer," "Forcman," "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 (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, tho DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cere- brospinol fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobor 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 volvulor heort 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 Nomenelature 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 otlier 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], whero contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chop. 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 tho 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 Lows, Chap. 78, Scc. 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 tho view of the dead bodies of only such persons as are supposed to have come to their death by violence. - Revised Laws, Chop. 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.
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