USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1904-1905 > Part 1
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Rec
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
(copa) 166
RETURN OF A DEATH
FULL NAME
Alice Rochefort
Registered No. /
Place of Death *
No. Chelmsford)
Date of Death.
Jan, 2, 19040
Age.
. years.
6
months
6
days
STATISTICAL DETAILS
SEX
.Fr
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE#
No. Theluns ford
NAME OF
FATHER
Gleophas
BIRTHPLACE
OF FATHER#
bancada
MAIDEN NAME
OF MOTHER
Marie Allen
BIRTHPLACE OF MOTHER # Canada
OCCUPATION
INFORMANT §
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from.
190 ..... to
.190
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
(DURATION) 2
DAYS
Contributory :
Convulsions
.(DURATION).
DAYS
(Signed)
M.D.
1
Jane 30
.190 (Address) Jangsboro
SPECIAL INFORMATION only for Hospitais, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
How long at
Place of Death ?
Days
Where was disease contracted, If not at place of death ?
Filed Jan 4
190
Groot Parkhurst
Sown Clerk
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
St. Joseph Cemetery four 4
. 1904
UNDERTAKER
foreich revert
ADDRESS
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If in a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
# State or country; also city, town or county, If known.
§ Name and address of person giving statistical detalls. || Name of cemetery.
=
1
-
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Priscilla Pierce
Registered No.
Place of Death *
Chelmsford Center
Date of Death
Jan 5 1904
Age
705
years.
months
24
.days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME +
Reeves
HUSBAND'S NAME +
Um S.Pierce
BIRTHPLACE # Salem
NAME OF
FATHER
Um Reeves.
BIRTHPLACE
OF FATHER#
Salerm
MAIDEN NAME OF MOTHER
BIRTHPLACE OF MOTHER #
OCCUPATION
INFORMANT § hms Prince Chaletand.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Due. 30 190 .. 3 .. to Jan. 5 1904 that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
Senile degeneration.
(DURATION). DAYS
Contributory :
(DURATION). DAYS
(Signed)
.M.D.
.. 190. .... (Address).
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?.
.Days
Where was disease contracted, If not at place of death ?
Filed face.7
1904
Gro F. Sarlheart
Cour Clerk
PLACE OF BURIAL OR REMOVAL !! Edam Com. Sowell
DATE OF BURIAL
Jane 7 1904
UNDERTAKER Walter Perface
ADDRESS
Chelmsford.
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow. # State or country ; also city, town or county, If known.
§ Name and address of person giving statistical details. | Name of cemetery.
61
Rec
Rec
MARGIN RESERVED FOR BINDING
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COMMONWEALTH OF MASSACHUSETTS
168
RETURN OF A DEATH
FULL NAME
Delia Pendergast
Registered No.
3
Place of Death "
East Prehnstand 11 atd
Date of Death.
Dans 5 TH
Age 27
years.
.months.
days
STATISTICAL DETAILS
SEX
He
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME + Delia Waldron
HUSBAND'S NAME + Joseph Pendersal
BIRTHPLACE # Ireland
NAME OF FATHER John Waldron
BIRTHPLACE OF FATHER# Ireland
MAIDEN NAME OF MOTHER Bridget farming
BIRTHPLACE
OF MOTHER #
Ireland
OCCUPATION Weaver
INFORMANT § Huskand
PHYSICIAN'S CERTIFICATE 1
I HEREBY CERTIFY that I attended deceased during last iliness, from 2015 1903 .. to JEe31 1903, that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
Lubera Cerebro men-
seite
Contributory :
Tuberculo
. (DURATION
20
DAYS
(DURATION) .DAYS
(s)gned) ..
M.D.
Lau G .190 5(Address) Lauree Mass
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents,
Former or Usual Residence
How long at
Place of Death ?
.Dayı
Where was disease contracted, If not at place of death ?
Filed Jan 6 19 Geo, r Jarkhush - jour Clerk
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
0 Janeks.
ADDRESS
UNDERTAKER C.H. Malloy Lavello
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If in a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow.
# State or country ; also clty, town or county, If known.
§ Name and address of person giving statistical details. il Name of cemetery,
٠
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
=
COMMONWEALTH OF MASSACHUSETTS
169
RETURN OF A DEATH
FULL NAME
Martha Holt
Registered No.
Place of Death *
Chelmsford Centre
Date of Death ..
Jamara
mary 12 1904
Age ..
805
years
/
.. months
26
.days
STATISTICAL DETAILS
SEX
COLOR
w.
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Widowed
MAIDEN NAME +
Woordand
HUSBAND'S NAME }
Samil Holts
BIRTHPLACE ¢
Thetford
NAME OF
FATHER
Theodore Woodard
1
BIRTHPLACE
OF FATHER#
Masa
MAIDEN NAME
OF MOTHER
Makitabal Spalding
BIRTHPLACE
OF MOTHER #
Mass
OCCUPATION
Housewife
INFORMANT § AWHolt Chelmsford.
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL Forefathers Com Chelmsford Jan 14. .... 1904
UNDERTAKER Walter Perhar
ADDRESS Checkingfor
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from ..... .: Jan. 9td 1904 to Jan. 12 1900 that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
Bronchitis
.. (DURATION) ..
8
DAY8
Contributory :
Old age
(DURATION). .. DAYS
(Signed)
Chmura Atoward.
M.D.
Jan- 12 1904 (Address).
Chelmsford.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?.
Days
Where was disease contracted, If not at place of death ?.
Filed face 13
6- Geo Parkhurst
Clerk
* City or town, street and number, if any, If death occurs away from USUAL RESI- DENCE, glve facts called for under "Speclal Information." If in a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. # State or country ; also city, town or county, If known.
§ Name and address of person giving statistical detalls. li Name of cemetery.
二
N
Rec
COMMONWEALTH OF MASSACHUSETTS
170
RETURN OF A DEATH
FULL NAME
Silvia E.
Sale
Registered No.
Place of Death *..
Chelmsford. Mas
Date of Death Jan. 13 . 1904.
Age.
11
years.
months
days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED,
WIDOWED, OR.
Female wirite
MAIDEN NAME + Silvia E. Sale
HUSBAND'S NAME !
BIRTHPLACE + Forwell, maso.
NAME OF FATHER Charles Sale
BIRTHPLACE OF FATHER + augusta maine
MAIDEN NAME OF MOTHER Sarah balder
BIRTHPLACE OF MOTHER +
Eastbeat, Main -.
OCCUPATION
none
INFORMANT §
father
PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Edson Cemetery Jan 01100H
UNDERTAKER
ADDRESS
6.In young the 33 Mesces ff
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness,
from
Jan
1902
.... to.
Land 3
1904
that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary : Pneumonia.
(Duration) Days
Contributory :.
ubercularis
(Duration)≤ Days
(Signed;
Aquingeloro x 1904 (Address) Lowell Mes
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?
Days
Where was disease contracted. if not at place of death ?
Filed Jan 15 1904 Goo. A. Parkhurst Jowy Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESIDENCE, give facts called for under " Special Information." If in a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow.
# State or country: also city, town or county if known.
§ Name and address of person giving statistical details.
IL_ Name of cemetery.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
-
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Hugh ... Keiren
Registered No.
58
Place of Death *
St. John's Hospital Lowell Mass.
Date of Death.
January ... 13 .... 19.04.
Age.4.5.
.years ..
months
days
STATISTICAL DETAILS
SEX
COLOR
M
W
--
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
S
MAIDEN NAME Ť HUSBAND'S NAME Ť
BIRTHPLACE # East Chelmsford
NAME OF
FATHER
Thomas Keiren
BIRTHPLACE
OF FATHER#
Ireland
MAIDEN NAME
OF MOTHER
Mary Little
.
BIRTHPLACE
OF MOTHER #
Ireland
OCCUPATION
Fatmer
INFORMANT §
Win Casey ( Cousin )'
PLACE OF BURIAL OR REMOVAL II St. Patrick's Cem.
DATE OF BURIAL
Jan ... 15.
...... 190.4
UNDERTAKER J. J. O'Connell & Co.
ADDRESS
lolo Central
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Jan 11 19 to Jan 13 .. 190 that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
Pneumonia
. (DURATION) .. . DAY&
Contributory :
Pneumonia
.. (DURATION). . DAYS
(Signed)
Jas. B. O'Connor
M.D.
Jan 14
1909 (Address) LOWell
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence E. Chelmsford
How long at
Place of Death ?2
.Days
Where was disease contracted,
Lowell Mass.
If not at place of death ?
Filed
Jan 14
1904
Girard 2. Dachman
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
# State or country ; also city, town or county, If known.
+§ Name and address of person giving statistical details, 4| Name of cemetery.
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
1 7/
Reg+
Rec
0
192
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A
DEATH
George adamo Parkhurst
FULL NAME
.. Registered No.
Place of Death *
Chelmsford Centre
Date of Death.
february 3rd 1904
Age 70
years.
05
.. months.
23
.days
STATISTICAL DETAILS
SEX
Male
COLOR
White
SINGLE, MARRIED
WIDOWED, OR
DIVORCED
married
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE #
Chelmsford
NAME OF
FATHER
Solomon Parkhurst
BIRTHPLACE
OF FATHER#
Chehusford
MAIDEN NAME
OF MOTHER
Sucina M. adams
BIRTHPLACE
OF MOTHER#
Boston
OCCUPATION
Editor
INFORMANT §
Truthof a. Parkhurst
Chelmsford
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from Jan. 29, 1904 to Cheb 3, 1904, that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary : Bronchopneumonia
Vi
.(DURATION).
DAYS
Contributory :
Vascular Degeneration -
Indefinito (DURATION).
.. DAYS
(Signed)
Fitting & Scobona, M.D.
Feb. 5 1904 (Address)
Chelmsford, Max
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
How long at
.Place of Death ?..
.Days
Where was disease contracted,
If not at place of death ?.
Filed-
tel. 20 1904
Edward J. Robbins
Clerk
Coun Besten.
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. # State or country; also city, town or county, If known.
§ Name and address of person giving statistical details. || Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVAL !!
Horsfactors Com. Chelanful
DATE OF BURIAL
1904-
UNDERTAKER
Halten Perlas
ADDRESS
Chelangford
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
-
RETURN OF A DEATH
FULL NAME
Margaret Sullivan
Place of Death *
Eastchelmsford Mass
Date of Death
Lieb 19
1904
Age.
70
-
months
days
STATISTICAL DETAILS
SEX female
COLOR White
SINGLE, MARRIED,
WIDOWED, OR
MAIDEN NAME T
Casey
HUSBAND'S NAME Ť
Eugene Sullivan
BIRTHPLACE + Ireland
NAME OF FATHER Unknown
BIRTHPLACE OF FATHER +
Ireland
MAIDEN NAME OF MOTHER Unknown
BIRTHPLACE OF MOTHER +
Ireland
OCCUPATION at Home.
INFORMANT S John Sullivan
PLACE OF BURIAL OR REMOVAL St Patricks
DATE OF BURIAL
Fick 22
1904
UNDERTAKER
ADDRESS
IH Me Dermott 70 Gorham it
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from nov. 13 .190.3 .. to. +46.18 1904 that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
acute nehositio
(Duration) mon, Days
Contributory :
Bronchitis
(Duration) 2 mas, Days
(Signed;
Umasatowere
M. D.
46.20
190 4 (Address)
Chelmsford.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?
Days
Where was disease contracted. if not at place of death ?
le Feb. 21 1904 Eduard J. Robbins Town Clerk Potem
* City or town, street and number, if any. If death occurs away from USUAL, RESIDENCE, give facts called for under " Special Information." If in a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow.
+ State or country: also city, town or county if known.
§ Name and address of person giving statistical details. Name of cemetery.
0-c >178
7
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
173
COMMONWEALTH OF MASSACHUSETTS
(
Registered No. 8 -
years.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Place of Death *.
Date of Death
Seb 2 24, 190 %
years months days
STATISTICAL DETAILS
SEX
female
COLOR In het
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME T
HUSBAND'S NAME Ť
Ellen Jung Michael Larkin Jufand
BIRTHPLACE +
NAME OF FATHER
Pating Ting
BIRTHPLACE OF FATHER +
Veland
MAIDEN NAME OF MOTHER
Ellen Mulcahy
BIRTHPLACE OF MOTHER 1
Unland
OCCUPATION
at Home
INFORMANT §
John Lassen, Un
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness,
from /4.6.1860 1904 to 426.22 1904 that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows:
Primary :...
neuve aiuto
(Duration)
Days
Contributory :
La Griffe
(Duration)
7
Days
(Signed;
M. D.
JE6.23 1904 (Address)
Chalmersford.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
Place of Death 9
Days
Where was disease contracted, if not at place of death ?
Filed Tich. 23 1904 Edward J. Roffin.
Tom
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESIDENCE, give facts called for under " Special Information." If in a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow.
* State or country ; also city, town or county if known.
§ Name and address of person giving statistical details.
|| Name of cemetery.
MARGIN RESERVED FOR BINDING
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PLACE OF BURIAL OR REMOVAL!
OfPatients cuentas
DATE OF BURIAL
Feb 24
1904
UNDERTAKER
.
ADDRESS
fat, AS men el Nino $24 mars et Sf
174
Ellen garten Morfo Theles ford Age
Registered No.
9
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
RETURN OF A DEATH
FULL NAME margaret Muller
Registered No.
10
Place of Death *
North chelmsford
Date of Death
Feb 22
1904
Age
70
years
months
days
STATISTICAL DETAILS
SEX
COLOR
Affito
SINGLE, MARRIED
·WIDOWED, OR
DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE + Ireland
NAME OF FATHER
Michael Muller
BIRTHPLACE
OF FATHER +
Ireland
MAIDEN NAME OF MOTHER Elisabetta Campbell
BIRTHPLACE
OF MOTHER +
Ireland
OCCUPATION
Not Home
INFORMANT § Hugh Muller
PLACE OF BURIAL OR REMOVAL !
St Patrick
DATE OF BURIAL Fiel 24
, 190 4
ADDRESS
UNDERTAKER 2 Holle Dennett 70 Gorham AT
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness,
from
Oct19
190 3 to how 12
1903 .. ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary :
Paralypro
(Duration)
126
Days
Contributory :
.. (Duration)
Days
(Signed;
Leonor Hohen
M. D.
fel 23
190 ..
(Address)
Lowell Way
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Former or
Usnal Residence
Place of Death ?
Days
Where was disease contracted. if not at place of death ?
Filed
Freb 23 1904 Edward J. Robbins
Joun
Clerk
* City or town, street and number, if any. If death occurs away from USUAL, RESIDENCE, give facts called for under " Special Information." If in a
Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow. # State or country ; also city, town or county if known.
§ Name and address of person giving statistical details. Name of cemetery.
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
1
COMMONWEALTH OF MASSACHUSETTS
175
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME Mary P
Jeadres Letrans Registered No.
11
Place of Death *
Estrelivsfare mars.
Date of Death
Feb. 24, 19104
Age 88
years
9
.. months.
20
.. days
STATISTICAL DETAILS
SEX
COLOR
w.
SINGLE, MARRIED, WIDOWED, OR- DIVORCED
MAIDEN NAME +
Mary Lindsey.
HUSBAND'S NAME + E Israel Putnam
BIRTHPLACE #
Marblehead Mars.
1
NAME OF FATHER
Dichard Lindsey
BIRTHPLACE OF FATHER# Marble head Mars.
MAIDEN NAME
OF MOTHER
Fone Devereux
BIRTHPLACE
OF MOTHERA
"Marble head, Mass.
OCCUPATION Housewife.
INFORMANT § Sarah Petriana
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from Med, 3 904 to Cheb. 24, 1904. that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
Influença
. (DURATION)
DAYS
Contributory :
Senility
.(DURATION).
DAYS
(Signed).
Autor y Scobona, M.D.
Feb. 25
f. 190 (Address).
Chelnstand, Mais.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
How long at
Place of Death ?
Days
Where was disease contracted, If not at place of death ?
Filed
Feb. 27 190.4. Edward . Robbie
Town
Clerk
Pro tem
* City or town, street and number, If any, If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. # State or country ; also city, town or county, If known.
§ Name and address of person giving statistical detalls.
We ter Pechan Gelwater, I'dName of cemetery.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVAL !!
thurs Gener. chefen mais
DATE OF BURIAL
Feb. 27
.. 1904
UNDERTAKER
ADDRESS
176
الل جة
١
COMMONWEALTH OF MASSACHUSETTS
177
RETURN OF A DEATH
FULL NAME
Leighton Meller Udams .
12
Place of Death *
Chelmsford, mais
Date of Death
Feb. 27, 19/04
Age.
1
years ..
5
.. months
3
.days
STATISTICAL DETAILS
SEX
m
COLOR
W.
SINGLE, MARRIED, WIDOWED, OR DIVORCED-
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
Chelmsford Mark.
NAME OF
FATHER
Umoe B. adams
BIRTHPLACE OF FATHER# Chehusfond, Mars Mars.
MAIDEN NAME
OF MOTHER
Hetty E Millen
BIRTHPLACE
OF MOTHER #
Este Vermont
OCCUPATION
INFORMANT § amos B. adams
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
Forfatter Comford. Meh. 1
. 190
190 ..
4
ADDRESS
UNDERTAKER Witter Perham Chelmsford.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from .. Frb. 16 .1904 to fut 27 1904, that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary : Intestinal Obstruction -
. (DURATION) 10
DAYS
Contributory :
Peritonitis
.(DURATION) ..
11
DAYS
(Signed).
Camera toward M.D.
Feb. 29 1904 (Address). Chelsea
SPECIAL INFORMATION only for Hospitals, Institutions, Translents, or Recent Residents.
How long at
Former or
Usual Residence
Place of Death ?.
Days
Where was disease contracted, If not at place of death ?
Filed
Feb. 29 1904. Edward . Robbing
Compra tin Clerk
* City or town, street and number, If any, If death occurs away from USUAL RESI- DENCE, glve facts called for under "Speclal Information." If in a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. # State or country ; also city, town or county, If known.
§ Name and address of person giving statistical detalls. || Name of cemetery.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
:
1
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
178
COMMONWEALTH OF MASSACHUSETTS
RETURN OF, A DEATH
FULL NAME.
Harriet A Spaulding
Registered No.
13
Place of Death *
Na
Chelvorstand Mass
Date of Death
I March 5 1904
Age ..
75
years
4
months
days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR
married
MAIDEN NAME + Harriet Littlehale.
HUSBAND'S NAME + Salman Spaulding
BIRTHPLACE + Jamasboro mass
NAME 9A. FATHER
Littlehale
BIRTHPLACE OF FATHER +
ang stan mass
MAIDEN OF MOTH
Parret Butterfield
BIRTHPLACE . OF MOTHER
ungerand.
OCCUPATION
House Wife
INFORMANT $
wester I dall
1
PLACE OF BURIAL OR REMOVAL "
DATE OF BURIAL
allary 190 4
UNDERTAKER
ADDRESS
1
John Wemeer Middlesen
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness,
from
Jamy H 1904 to.
Klardo 3 190.
that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
Diabetes
(Duration) Days
Gang rene of food.
Contributory :
(Duration) Days
(Signed;
2200/ 190% (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?
Days
Where was disease contracted. if not at place of death !
Filed March 7 1904 Edward J. Robbins Clerk Dr. ten.
* City or town, street and number, if any. If death occurs away from USUAL RESIDENCE, give facts called for under "Special Information." If in a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow.
# State or country; also city, town or county if known.
§ Name and address of person giving statistical details.
|| Name of cemetery.
0-c 8178
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
Fee
-
179
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
6tis adams
Registered No.
14
Place of Death -*
Chelmsford Mase
Date of Death.
march 12 1904
Age.
78
. years.
2
.months
6
.days
STATISTICAL DETAILS
SEX
COLOR
W.
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME 1 HUSBAND'S NAME +
BIRTHPLACE #
Chelmsford, Mase.
NAME OF
FATHER
Otis adami
BIRTHPLACE
OF FATHER#
Chelmsford, Mark.
MAIDEN NAME
OF MOTHER/
Abigail Gegood Read.
BIRTHPLACE OF MOTHER V Westford Mark.
OCCUPATION
trammer
INFORMANT § (Otis adams.
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
Hore altura Semetery March 16 15
1904
UNDERTAKER
ADDRESS
Water Perham Shelmeten
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last iliness, fro March 10, 190 4 to March 12, 904. that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
accident, Injury to
head-
Concession offriamo
(DURATION) 2 DAYS
Contributory :
(Signed)
Arthur y Acolonia -
M.D.
(DURATION).
.. DAY8
March 14/ 1904 (Address).
Chelofound, mas.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
How long at
Place of Death ?.
Days
Where was disease contracted,
If not at place of death ?
Filed
March 15
190%
Eduard J. Rothings,
Von Clerk Protein
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME instead of street and number.
t in case of married or divorced woman, or widow.
# State or country ; also city, town or county, If known.
§ Name and address of person giving statistical details.
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