USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1920-1921 > Part 8
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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- brospinol 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); Meosles; Whooping cough; Chronic valvular 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 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, Chop. 29, Secs. 10 and 1, as amended by Acts of 1910, Chop. 322.
1
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. - Reviscd 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 persen 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, 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 ferm 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
...
(City or Town)
20
City or Town
Narty Chehunford.
St .. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number) Dugas
2 FULL NAME
Octavia
( If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No ..
Cold Baston Road
St.
Ward.
(If non-resident give eity or town and State)
Length of residence in city or town where death occurred 2
years
mooths
days.
How loog io U. S., if of foreigo hirth ?
36
years
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Month)
aput
1
(Bay)
1420
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
March
30
1920, to Ofsie
1
1920
..
that I last saw her alive on
1920
and that death occurred, on the date stated above, at
1185th
The CAUSE OF DEATH was as follows:
1
Peritonitis
Canzed by user in .(duration) .. yrs.
stomach
mos ...........
.ds.
CONTRIBUTORY. (SECONDARÝ)
(duration)
............. yrs ..............
mos.
ds.
18 Where was disease contracted
if not at place of death ?
Was there an autopsy ?
/h.
What test confirmed diagnosis ? (Sigue) Frank E Quelisas
M.D.
(Addres to Chele Fond
Date april
(Month)
(Day)
3
1920
(Year)
Informant.
Husband
North Chelunch and
Filed .. (Month) (Day) (Year)
REGISTRAR
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the horial or transit permit was issued Edward J. Rohtang
Official
position
Coron Clerk
Date of issue of permit .... Ochun, 5, 1920 No.
Permit
11-13-19. 50,000.
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Marked
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
antoine Dugas
6 DATE OF BIRTH
dept
(Month)
45-1848 (Day)
(Year)
4ª Years 71.
Months 6
Days
16
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
at Home
Canada
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
Deandre Mudrace d an operation precede d
11 BIRTHPLACE OF
FATHER (City).
(State or country)
Camada
12 MAIDEN NAME
OF MOTHER
Catherine Jaukin
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Canada
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
St Joseph & blutungand
(Cymetery) (Clty of town)
DATE OF BURIAL
april 5 1920,
ADDRESS
738
15 Uhr. 5,1920 Edward J. Robbing
20 UNDERTAKER A Archambault Mermach
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
3 SEX Le 7 AGE 7€ PARENTS 14 (Address) should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH (h) Name of employer
The Commonwealth of Massachusetts
31
1 PLACE OF DEATH
County.
middlerel
State Mars Registered No
MARGIN RESERVED FOR BINDING
( Usual place of abode)
months
days
Date of.
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census aod American Public Health Association!
Statement of occupation. - Precise statement of occupation is very important, so that the relative healthfulness of varieus 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 fireman, etc. Butin many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (0) 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; (o) Solesmon, (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 Doy laborer, Farm laborer, Laborer - Coal mine, cte. Women at home, who are engaged in the duties of the house- hold only (not paid Ilousekcepers 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, Housemoid, 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.
$
1
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 fcver (the only definite synonym is "Epidemie cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonio; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, men- inges, peritoneum, etc., Corcinoma, Sarcoma, etc., of ..... .. (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Meosles; Whooping cough; Chronic valvulor heort diseose; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Bronchopneumonio (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," ete., when a definite disease can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septiccmio," "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 lis knowledge and belief the name of the deceased, 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 Lows, Chop. 29, Secs. 10 and 1, as amended by Acts of 1910, Chop. S22.
No undertaker or other persen 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 persen 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 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 Lows, 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 persens as are supposed to have come to their death by violence. - Revised Laws, Chop. 24, Sec. 8.
à
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 ferm of injury.
(2) Board of Health Physicians will certify to such deaths only as those of persens 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 ((Irugs or poisons), thermal, or electrical agents, and deaths following ahortien, but also deaths from disease resulting from injury or infectien related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
.
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
(City or town)
1 PLACE OF DEATH
County
middlesex
State
mass
Registered No ..
2/
(Place of residence)
City or Town
Lowell
henry - allard to St.
Ward
(If death occurred in a hospital or institution, give Its NAMEinstead of street and number)
essin Bell norton
(a) Residence.
State
(Usual place of abode)
Thelmal
ord, City of Town
mb (Ifin the Army or Navy of the United States, give rank, organization, etc.)
Chelmsford
St.
Length of residence in city or town where death occurred
years
2
months
days
How long in U. S., if of foreign birth?
years
months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and yea Dupri 2/ 1920
17 I HEREBY CERTIFY, That I attended deceased from
Jeb
1920
Capac. 21, 1920
that I last saw bek alive on
21
1920,
and that death occurred, on the date stated above, at ........ bom.
If LESS than
The CAUSE OF DEATH* was as follows :
* State the DISEASE CAUSING DEATH, or In deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (Sce reverse side for additional space.) Phlegmasia alla Willens
(duration)A.
·
Childby
.......
. yys ...
1
.mos
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
-yrs.
12 days
mos.
before
AV.
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 shall ho alling
-29, 1920 (Address)
elf
4
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
die Gmetery Chelmsford, mais por. 25- 1920
20 UNDERTAKER ADDRESS Walter Perham Chelmsford
makes.
MARGIN RESERVED FOR BINDING
14 15 of certificate. N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of Information should be PARENTS
2 FULL NAME 3 SEX 7 AGE Years 40 (b) General nature of industry, business, or establishment in which employed ( or employer ) (c) Name of employer (State or country) so that it may be properly classified. Exact statoment of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be'stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, If STILLBORN, enter that fact here
4 COLOR OR RACE
w.
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Good
6 DATE OF BIRTH (month, day, and year may 1, 1879
Months
20
Dalys.
I day, ........ brs. or ....... min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
aroma
9 BIRTHPLACE (city or town) howell
masa.
10 NAME OF FATHER
a. S. Sargent
Charlestown
11 BIRTHPLACE OF FATHER (city or town) (State or country) mars.
12 MAIDEN NAME OF MOTHER Lasweeney
13 BIRTHPLACE OF MOTHER (city or town) (State or country)
Rodney (Signed)
Informant (Address) Chelmsfordmass
Lepor. 29, 10 20 stephen Flyna (P) a Thay 8. 1920 Edward J. Robbing
Registrar of city or town where death occurred
Registrarlof city or town where deceased resided
32 howell
Registered No.
(Place of death)
.. , M.D.
4.32
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise stat. ur occupa- tion 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, Compos- itor, Architcet, Locomotive engineer, Civil engineer, 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "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 houschold 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- eifically 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 faet may be indi- catcd 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 discase. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, ete., of_
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); 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 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toins or terminal conditions, such as "Asthenia," "Ancmia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"" "Debility"? (“Con- genital," "Senile," etc.), "Dropsy," "Exhaustion,". "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease ean be ascertained as the eause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
..
R 303. 6-'18. 50,000.
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
1 PLACE OF DEATH
Registered No.
(Place of death)
County
middlesex
State
ma
Registered No.
29
City or Town
Lowell
(Place of residence)
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number) Buntel
mass
City or Town ....... helmaford No.
St.
Length of residence in city or town where death occurred
years
months
days
How loog in U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and yea ) Gare) 26 1920
17 HEREBY CERTIFY, That I attended deceased from
april 24
20,0 april 26. 2020
that Ilast saw halive on
26 10 20.
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows :
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL,, or HOMICIDAL, (See reverse side for additional space,) Septicemia and .
Lobar Pneu
monia
....... (duration).
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