USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1898-1899 > Part 15
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Married Occupation,
Carpenter
*Residence, also state fully. )
{ If out of town, {
Chelmsford
Place of Birth,
Springfield Vermont
*Place of Death,
Chelmsford
Name of Father, Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,
Place of Interment, (Give name of Cemetery),
Edson Cemetery Lowell
Dated at Chelmsford
Signature and
-
Walter Perham
on
Dre 9
189 9
place of business
of Undertaker.
Chelmsford
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t Char, Calvin War
Age, 64 Y. 11 M. O D. died at Chelmsford, Maxx, Dec. a 182
Place and Date of Death,#
Disease or Cause of Death, §
Chrome Patricia
Duration of sickness,
Indefinite,
I certify that the above is true to the best of my knowledge and belief.
Siguature and Residence
Arthur J. Scolonia
M. D.
of Certifying Physician. Chelunsford, mark.
Date of Certificate, 11 1899 .
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. # If child dled immediately after birth, so state.
§ If a Soldier or Sailor In the War of the Rebellion, give both Primary and Secondary Cause.
1
No.
RETURN OF THE DEATH
OF
at
Date,
189
Filed,
189
The provisions of chapter 444 of the Aets of 1897 require that every householder in whose house a death oecurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred. (See section 6.)
The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death. (See section 7.) Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars. (See section 8.)
A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts. (See section 10.)
Penalty for refusal or neglect, ten dollars. (See section 11.)
Any person having charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certifieate made in accordance with seetion 10, and return it, together with the facts required by seetion 1, to the board of health or to the clerk of the city or town in which the death occurred.
1
1
Rec
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Joanna
Trubel
7
Sex,
Fi
. Color,
Date of Death,
Dec. 11th
1899; Age, 88 Years,
1
. Months,
.Days.
Maiden Name, { If married, widowed )
or divorced.
Joanna
Stanburg
Husband's Name,
George E. Truber
Single, Married, Widowed or Divoreed, ..
North Chelmsford Mass.
*Residence, { If out of town, )
also state fully. )
Place of Birth, England
*Place of Death,
North Chelmsford Mais.
Name of Father,
John Stanbury
Birthplace of Father,
England
Maiden name of Mother,
Birthplace of Mother,
England
Place of Interment, (Give name of Cemetery), North Chelmsford Cemetery
Dated North Chelmsford
Signature and
Arthur A. Sheldon
on Der.
11h
1899
place of business
of Undertaker. North Chelmsford
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, f
franna
Varley
Age 68 Y / M.
.D.
Place and Date of Death, ¿ died at north Chehunting Dec 11- 1899
Disease or Cause of Death, §
Pneu monia
Duration of sickness,
one week
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
F. G. Varney
M. D.
of
Certifying Physician.
North Chihunfund
Date of Certificate,
Dec 11ch
189 9.
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. { If ehild dled immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
A
Widow
Atarreed Occupation,
-
No. RETURN OF THE DEATH
OF
at
Date,
189
......
Filed,
189
The provisions of chapter 444 of the Acts of 1897 require that every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of sueli a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred. (See section 6.)
The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death. (Sec section 7.) Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars. (See section 8.)
A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required faets.
Penalty for refusal or neglect, ten dollars. (See section 11.) Any person having nhgroc of the firereal .
1_ _ hall ohtain the physician's ofinate mai 2
(Sec section 10.)
O. Jin ce we the clerk of the
Rec FORM C.
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH. To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Edith & Mulino
Name, ...
Date of Death,
Dee 11
1899; Age, 2.6
. Years,
.Months,
22 Days.
Maiden Name, {
married, widowed į
Ebert
or divorced.
Husband's Name,
walter H Mucho
SinNe, Married, Widowed or Divorced, Occupation, It Home
* Residence,
{ If out of town, {
also state fully )
Chelunsford, Mass
Place of Birtlı,
* Place of Death,
Chelmsford
Name of Fatlier,
Horact In Ebert
Birthplace of Father,
Chelmsford
Maiden Name of Mother,
Mary & Dennett
Dillspieler MH.
Birthplace of Mother,
Place of Interment, (Give name of Cemetery),
Lowell Cemetery
Lowell
Dated at Lowell Dee 11/99. Signature and place of business of Undertaker.
Blumen Lowell
011
I
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt Edith Le mulno
Age,. 26 x 5 M 22 D.
Place and Date of Deatlı, died at Chelmsford I
Disease or Cause of Death, #
Duration of sickness,
Indefinite.
I certify that the above is true to the best of my knowledge and belief.
Auchin G. Scolonia M. D. Signature and Residence { of Certifying Physician.
Date of Certificate Dec,, 11 1899
* Give also street and number, if any.
+ Give sex of infant not named. If still-born, so state. If child died immediately atter birth, so state.
# If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Ir Acaboria
112
Sex Female Color,
Pittsfield MH
No.
RETURN OF THE DEATH.
OF
at
I
Date,
Filed,
I
Acts of 1897, Chapter 444 [EXTRACTS FROM SECTIONS 6, 7, 8, 10, II AND 12.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION IO. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
SECTION II. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars. ..
SrcT
Rel
113
Commonwealth of Classachusetts.
No.
RETURN OF A DEATH. To the Clerk of the City of Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name, Jacob Spaulding
Sex,
Color,
Date of Death,
Drie Il
1899; Age, 90
Years,
5 Months,
15 Days.
Maiden Name,
{ If married, widowed }
or divorced.
Husband's Name,
Single, Married, Widowed or Divorced, Andneed
Occupation,
Harmer
* Residence, { If out of town, )
' { aiso state fully. §
Chelmsford
Place of Birth,
Billerica
*Place of Death,
Chelmsford
Name of Father,
Benoni Spaulding
Birthplace of Father,
Billerica
Maiden name of Mother,
Lydia Deren
Birthplace of Mother,
Carlisle
Place of Interment, (Give name of Cemetery).
Dated at
Chelmsford
Signature and
place of business
of Undertaker.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Place and Date of Death,
Disease or Cause of Death, §
Jacob Spaulding
died at.
Chelmsford, Was One, 1th.
1899
Age, 90 Y. 5 M. 15 D.
5
Duration of sickness,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
Edward St, Chambles
M. D.
of Certifying Physician. Chelmsford, Mass
Date of Certificate,
Give also street and number, if any.
t Or sex of infant not named. If stili-born, so state. # If child died immediately after birtil, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Canse.
on
December 11 1899
1
1
No ..
RETURN OF THE DEATH
OF
at
Date,
189. ...
Filed,
189 .... .
The provisions of chapter 444 of the Acts of 1897 require that every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred. (See section 6.)
The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death. (Sec section 7.) Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars. (See section 8.)
A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts. (See section 10.) Penalty for refusal or neglect, ten dollars. (See section 11.)
Any person having charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's c ricate made in accordance with section 10, and return it, together with the facts required by section 1, to the board of he ilth or to the clerk of the city or town in which the death occurred.
Rec
FORM C.
114/
Commonwealth of Massachusetts.
No. .........
RETURN OF A DEATH. To the Clerk of the City or Town In which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Elizabeth
Kelley
Sex Female Color,
Date of Death,
Der 14
. 1899; Age, 82
Years,
2
Months,
26
Days.
Maiden Name, { If married. widowed }
or divorced.
Shephard
Husband's Name, Daniel Kelley
Single, Martied, Widowed or Divorced,.
Occupation,
At home
*Residence, {If out of town, { ( also state fully )
Gorham It East Chcemefac
Place of Birth,
* Place of Death,
East Chelonefour
Name of Father,
Philip Sheppard
Birthplace of Father,
Maiden Name of Mother,
Theartha Ling
Birthplace of Mother,
Bradford ChH
Place of Interment, (Give name of Cemetery),
Edson Cemetery Lowell
Dated at.
Lo well
Signature and
JA Currier
011 dee 14
1899
place of business
of Undertaker.
Lowell
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt Elizabeth Kelly Age, 82 x 2 M 26 D.
Place and Date of Death,
died at
East chelmsford
I
Disease or Cause of Death, #
Pneumonia
Duration of sickness,
Three days
I certify that the above is true to the best of my knowledge and belief. .
Signature and Residence
Charmer A. Velez
M. D.
Certifying Physician.
Date of Certificate
18.99
· Give also street and number, if any.
t Give sex of infant not named. If still-born, so state. If child died immediately after birth, so state.
* If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
de Miles
Strafford (11
1
No. RETURN OF THE DEATH.
OF
at
Date,
I
Filed. ...
I
....
Acts of 1897, Chapter 444. [EXTRACTS FROM SECTIONS 6, 7, 8, 10, II AND 12.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town inl which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his chiarge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
SECTION II. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. ; Penalty for refusal or neglect, ten dollars. .
SECTION 12. Any person having slapen of why
Rec
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Rufus Francis Emerson
Sex,
m
Color,
Date of Death,
December 16
1899 ; Age,
64 Years,
2
Months, 27 Days.
Maiden Name,
or divorced.
married, widowed {
Husband's Name,
Single, Married, Widowed or Divoreed,
Married Occupation,
Fruit Dealer
*Residenee, {If ont of town, )
? also state fully. §
Chelmsford
Place of Birth,
Chelmsford
* Place of Death,
Chelmsford
Name of Father,
Franklin Emerson
Birthplace of Father,
ThelmaAnd
Maiden name of Mother,
Rebecca adamo Kittredge
Birthplace of Mother,
Place of Interment, (Give name of Cemetery).
Chelmsford Center
Dated at.
Thelmaford
Signature and
Halter Perham
on
Arcember 16
1899
place of business
of Undertaker.
Chelmsford
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t Rufus Francis Emerson Age, 64 Y. 2 M 29 D.
Place and Date of Death, ¿
died at.
Chelmsford Die, 16 00
189.9
Disease or Cause of Death, §
Paralysis
Duration of sickness,
Several months.
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S
of
Certifying Physician.
Amara toward -
M. D.
Date of Certificate,
Dec. 17 th
1899.
Give also street and number, if any.
{ If child died Immediately .after birth, so state.
t Or sex of infant not named. If still-born, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Canse.
115
No.
RETURN OF THE DEATH
OF
at
Date,
189
Filed,
189
The provisions of chapter 444 of the Acts of 1897 require that every houscholder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred. (See section 6.)
The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death. (Sec section 7.) Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars. (See section 8.)
A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts. (See section 10.)
Penalty for refusal or neglect, ten dollars. (See section 11.)
11 cereal site nuliminare to the interment of a human body shall obtain the physician's 1 .the board of
Rec
FORM C.
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH. To the Clerk of the City or Town in which the death occurred.
Name,
Kasse Plante
Sex,fe
Color,
Date of Deatlı,
Dei 19
1899, Age, 25 Years,
Months,
Days.
Maiden Name, { If married, widowed ) or divorced.
Marie Patenaude
Husband's Name,
Joseph Plante
Single, Married, Widowed or Divorced,
Occupation,
* Residence,
( also state fully )
Granada
* Place of Death,
North Chelmsford
Name of Father,
Grasped
Potomande
Maiden Name of Mother,
Octance
Trudeau
Birthplace of Mother,
Place of Interment, (Give name of Cemetery),
MI Joseph God- Chehurford
Dated at
Laull
Signature and
If Archambault
011 Dec19899 place of business of Undertaker.
740 Nummach Sau
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt Rose Plante
Age, 250
Y. ........ M. D.
Place and Date of Death,
died at
North Chaleur ford, Dec 19,899
Disease or Cause of Death, #
Consum phen
Duration of sickness,
one year
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S
of
FE Janney
M. D.
Certifying Physician.
y, chekaster
Date of Certificate
Dee /que
1699
* Give also street and number, if any.
t Give sex of infant not named. If still-born, so state. If child died immediately after birth, so state.
# If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
116
(FILL OUT WITH INK. . ALL NAMES TO BE IN FULL.)
( If out of town, {
North Chelmsford
Place of Birth,
Birthplace of Father,
Canada
Canada
No. RETURN OF THE DEATH.
OF
at
I
Date,
Filed,
I!
Acts of 1897, Chapter 444. [EXTRACTS FROM SECTIONS 6, 7, 8, 10, II AND 12.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION IO. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
SECTION II. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.
SECTION 12. Any person having charro of the ...... shall obtain the phy.
quired by section
het
FORM C.
117
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH. To the Clerk of the City or Town in which the death occurred.
FILL OUT WITH INK.
ALL NAMES TO BE IN FULL.)
Name,
Pavold & Brown
Sex UMbrite Color Male
Date of Death,
ECO 2 201 . 189 %, Age, 3
Years, Months, Days.
Maiden Name, { If married, widowed )
or divorced.
Husband's Name,
Single, Married, Widowed or Diyorged,
Occupation
* Residence,
( If ont of town, {
falso state fully i
Place of Birth,
* Place of Death,
Name of Father,
Birthplace of Father,
Jamesbugh, at
Maiden Name of Mother, Le cura
Birthplace of Mother,
-criartabela 01X
Place of Interment,
(Give name of Cemetery),
Dated at
Signature and
place of business
88 allidaleri
011
2.2-01 000
1899
of Undertaker.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
Ronald Exactes Brown.
... Age, 3 v. /
D.
l'lace and Date of Deatlı, died at Chelmsford, Mare.
Disease or Cause of Death, #
General Tuberculose's,
Duration of sickness,
Endefinite.
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S
.
2
Date of Certificate ..
1899.
* Give also street and number, if any.
Arthur y. Scoloria
M. D.
of
Certifying Physician.
Chebrafor, more.
t Give sex of infant not named. If still-born, so state. If child died immediately after birth, so state.
# If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Canse.
No.
RETURN OF THE DEATH.
OF
at
Date,
I
...
Filed,
I
Acts of 1897, Chapter 444.
[EXTRACTS FROM SECTIONS 6, 7, 8, 10, II AND 12.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
SECTION II. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.
SECTION 12. Any person having change of the funere .. ] rites protur. · interment of ¿ human body
shall obtain the physician's certificate made in accordance with station together wi the facts i
quired by section 1. to the board of health or to the clock of the city ' with the us th occurred.
Rec
FORM C.
Commonwealth of Massachusetts.
No. .....
RETURN OF A DEATH. To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Hannache De Butterfield
Sex, A
Color,
Date of Death, (Dec 17 1899; Age, 5'8 Years, 2 Months, 23 Days.
Maiden Name, { If married, widowed ) or divorced.
Husband's Name,
Single, Married, Widowed or Divorced,
Occupation, at Home
* Residence, ¡ If out of town, }
¿also state fully
Faith Elitenspar Chan
Place of Birth,
* Place of Death,
Name of Father, Butconcent
Stecher:)
Grafton dix
Birthplace of Mother,
Bristol MIX
Place of Interment, (Give name of Cemetery),
Dated at
20well
Dec 18'99,
011
Signature and place of business of Undertaker.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
Place and Date of Death,
Disease or Cause of Death, #
died at chouthe Chterstand Man Cancer
Duration of sickness,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence F.E. Janney M. D. of Certifying Physician. Dec 18h 1899
Date of Certificate
* Give also street and number, if any.
t Give sex of infant not named. If still-born, so state. If child died immediately after birth, so state.
# If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
118
..
Birthplace of Father, ( ..........
Maiden Name of Mother,
Hamzah I Butterferry 580 x 2 M 23 D.
No.
RETURN OF THE DEATH.
OF
at
Date,
I
Filed,
I
Acts of 1897, Chapter 444. [EXTRACTS FROM SECTIONS 6, 7, 8, 10, II AND 12.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
SECTION II. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten 1.11 ____
1 .man hndv
certificat
.
11-
quired UV sec . , I, 1 , 1 board of her ..
clerk of the city Han Which the death occ.
Reu
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name, .....
Anna maria De Carteret
Sex,
.Color, W.
Date of Death,
Dec. 29 th
.. 1899 ; Age, 27_Years, 8 Months, Days.
Maiden Name,
{ If married, widowed }'
or divorced.
Anna Maria Carre.
Husband's Name,
Arthur De Carteret,
Single, Married, Widowed or Divorcest,
Occupation,
house kuper
*Residence, { also state fully. )
{ If out of town, }
N. Chelansford
masz.
Place of Birth,
Island of Very British Isles?
*Place of Death,
A Cheline fort, mass.
Name of Father,
Peter Carre
Birthplace of Father,
Jersey Island & B. S.}
Maiden name of Mother,
Jane Branger.
Birthplace of Mother,
laland & B.S. ?
Place of Interment, (Give name of Cemetery),
A. Chelmsford
Cemetery
Dated at
S. Chebusford
John Bratinel ys
on Dec29 st
189
Signature and
place of business
. of Undertaker.
A. Chelons ford frase
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t Uma Marca De Carboal. Are. 27 Y. 8 M. D.
Place and Date of Death,;
died at
northChehusfind, Dec 29ch.
189.9
Disease or Cause of Death, §
typhoid fever
Duration of sickness,
ten days
I certify that the above is true to the best of my knowledge and belief.
J.E. Varney
Signature and Residence S
of
M. D.
Certifying Physician.
north Chelmsford
Date of Certificate,
Dee 29
1899.
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state.
{ If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
119
No.
RETURN OF THE DEATH
OF
at
Date,
189
..
Filed,
.1
189
..... .
The provisions of chapter 444 of the Acts of 1897 require that every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death oceurred. (See section 6.)
The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after sneh death. (See section 7.) Penalty for neglect to comply with the requirements of seetions 6 and 7, five dollars. (Sec section 8.)
A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts. (Sce section 10.)
Penalty for refusal or neglect, ten dollars. (Sec section 11.)
Any person having charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certifieate made in accordance with section 10, and return it it" the facts required b the board of licalth or to the clerk of the city or town in which " .; occurred.
4
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