Deaths 1900-1901, Part 12

Author: Chelmsford (Mass.)
Publication date: 1900-1901
Publisher:
Number of Pages: 308


USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1900-1901 > Part 12


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19


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 refnsal or negleet, ten dollars. (See section 11.)


... IT- interment.nl - Luggage 1


7


17 1 .


-1


Rec


FORM C.


No.


RETURN OF A DEATH. To the Clerk of the City or Town in which the death occurred.


Name,


Graciela Michel


(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)


Sex.


Hemale Color While


Date of Death,


Het. *


1901


. 189 ; Age,Years,


Months,.


Days.


Maiden Name, { If married, widowed ) or divorced.


Husband's Name,


Single, Married, Widowed or Divorced,


Jungle


Occupation,


*Residence, { If out of town, )


falso state fully )


Forth Chelmofor& Max


Place of Birth,


Lawrence Maxx


* Place of Death,


# North Chelmsford Mars


Name of Father,


Hector Michel


Birthplace of Father,


Canada


Maiden Name of Mother,


anna Provencher


Birthplace of Mother,


canada


Place of Interment, (Give name of Cemetery),


It Joseph Cemetery


Dated at ...


Low all Mass


Joseph Albert


Signature and place of business of Undertaker.'


#54 Cheever


PHYSICIAN'S CERTIFICATE.


Name and Age of Deceasedt


Place and Date of Death,


Disease or Cause of Death, #


Whooping Cough


Duration of sickness,


Beventes


I certify that the above is true to the best of my knowledge and belief.


Signature and Residence


J.E Jamey


M. D.


of


Forth Cherchent Thors


Date of Certificate


1901


* 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 Sallor in the War of the Rebellion, give both Primary and Secondary Cause.



Fraciella Michel


Age,


Y ..


4 M ...


.


D.


died at


North Chilisford Man City 41901


on


1901


207


Commonwealth of Massachusetts.


Certifying Physician.


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 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 1 .11


1


208


FORM C.


Commonwealth of Classachusetts.


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,


Whatha A Blood


Sex Female Color,



white


Date of Death,


February 12


190 1; Age, 65 Years,


3


Months, 10 Days.


Maiden Name,


§ If married, widowed ?


or divorced.


Martha


of Crosby


Husband's Name,


John N. Blood


Single, Married, Widowed or Divorced, Married Occupation,


*Residence, { If out of town, )


¿ also state fully. }


Carlisle


mark


Place of Birth,


Octeville Mase


*Place of Death,


Chelmsford Mars


Name and Birthplace of Father,


Daniel Crosby


Maiden Name and Birthplace of Mother,.


ettigial Bodfish.


Place of Interment, (Give name of Cemetery),


Carlisle mask


Dated at Chelmsford More


Thomas . V.


on


February


13 th.


190 (


Signature and


place of business.


of Undertaker.


Carlisle Man.


PHYSICIAN'S CERTIFICATE.


Name and Age of Deceased, t


Martha a. Blood


.Age,


6.5 x 3 M. 10D.


Place and Date of Death,


died at


Chelmsford Mass.


Feb. 120.


190 ) .


-


Primary,


Myocarditis


Bronchitis


Duration,


I certify that the above is true to the best of my knowledge and belief.


Unnen Howard.


M. D.


Signature and Residence of Certifying Physician.


Chelmsford


Date of Certificate,


+06.13


190/ .


* Give also street and number, if any. t Give 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 Cause.


.


Countersign and transmit to the clerk of the city or town.


Agent of Board of Health.



1


Duration,


Several months


Disease or Cause


of Death, }


Secondary,


4


No.


RETURN OF THE DEATH


OF


at


Date,


190


Filed, 190.


[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]


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 11. 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 charge of the funcreal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordance with section 10, and return it, together with the facts required by section 1, to the board of health or to the clerk of the city or town in which the death occurred.


[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]


SECTION 1. No human body shall be buried in a city or town or removed therefrom, until a permit therefor shall have been received from the proper authorities. No such permit shall be issued until a written statement, as required by law, has been furnished, with a physician's certificate of the cause of death. When such statement and certificate arc delivered to the Board of Health the hand ...


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,


Date of Death,


tel 14


20 1, Age 25


Years,


6


Months,


Days


Maiden Name, { If married, widowed } or divorced.


Husband's Name,


Single, Married, Widowed or Divorced,.


Occupation,.


Highland dir Arth Philusford


* Residence,


{ If out of town, {


faiso state fully §


advocacia


Maryland.


Place of Birth,


* Place of Death, Highland an


Worth Thelucaford


Name of Father,


James Tale


Birthplace of Father,


Ireland


Maiden Name of Mother,


m. Vagy


Birthplace of Mother,


I Vertland


Place of Interment, (Give name of Cemetery),


Dated Jah12th201


Signature and place of business of Undertaker.


324 maiset St


PHYSICIAN'S CERTIFICATE.


Name and Age of Deceasedt


Place and Date of Death,


Disease or Cause of Death, #


Consumption


Duration of sickness,


Fourteen mounth


I certify that the above is true to the best of my knowledge and belief.


FE Vanily


M. D.


Signature and Residence


of


Certifying Physician.


North Chebefund 200


Date of Certificate


July 17h


1901


* 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.


Reda tal, 18-1901


on


William Tole


Age, 25 Y


6


M D.


died at


North Chelmsford Muro Jely 16 9.07.


209


Sex,


Color,


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 narenn how - 1


ec


FORM C.


Commonwealth of Atlassachusetts.


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,


Clarence Flanders Wright


Sex,


Color,


Date of Death,


Stab 17


1900; Age, 13


... Years, 1 Months 27 Days.


Maiden Name, { If married, widowed ) or divorced.


Husband's Name,


Single, Married, Widowed or Divorced, .Occupation,


*Residence, {If out of town, )


? also state fully. § Chelmsford


Place of Birth,


*Place of Death,


Name and Birthplace of Father, George B. B. Wright, Chelmsford


Maiden Name and Birthplace of Mother, .. Fadelaine Henshaw New Brunswick


Place of Interment, (Glve name of Cemetery),


Chelmsford Center Cemetery


5


Walter Perhan


Dated


Tab 17


190€


Signature and


place of business


of Undertaker.


Chelwaging


PHYSICIAN'S CERTIFICATE.


Name and Age of Deceased, f


letavance thandero Wright Age 3 x. / M 27 D.


Place and Date of Death,


died at ....


Chelmsford Feb. 17th


190/.


Disease or Cause


-


Primary,


of Death, ţ Secondary,


Duration,


I certify that the above is true to the best of my knowledge and belief.


Signature and Residence S


of


Amara Howard ~M. D.


Certifying Physician.


Date of Certificate,


426.


190/ .


* Give also street and number, if any. t Give 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 Cause.


Countersign and transmit to the clerk of the city or town.


Agent of Board of Health.


Scarlet Junker


Duration,


6 days,


1


on


110


No.


RETURN OF THE DEATH


OF


at


Date,


190 ...


Filed,


190


[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]


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 scctions 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 11. 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 charge of the funercal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordance with section 10, and return it, together with the facts required by section 1, to the board of health or to the clerk of the city or town in which the death occurred.


[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]


SECTION 1. No human body shall be buried in a city or town or removed therefrom, until a permit therefor shall have been received from the proper authorities. No such permit shall be issued until a written statement, as required by law, has been furnished, with a physician's certificate of the cause of death. When such statement and certificate are delivered to the Board of Health, the board or agent shall forthwith counter_n . nd transmit the same to the clerk of the city or town for registration.


SECTION 5. Penalty for violation not exceeding fifty dollars.


21/


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,


Charles Sweetser


Sex,


Color,


W.


Date of Death, March 4


190/; Age, 80


.Years, ..


11 Months,


9 Days.


Maiden Name, { If married, widowed ) or divorced.


Husband's Name,


Single, Married, Widowed or Divorced, ..


Widowed


Occupation,


Farmer


*Residence, also state fully.


{ If out of town, }


Chelmsford. Mars


Place of Birth,


Westrand


Mass


*Place of Death,


Chequesfond, Mass


Name and Birthplace of Father,


Elias Sweeties, Westford Mass (Probably)


Maiden Name and Birthplace of Mother, Mary ledams Chelmsford, Mass.


Place of Interment, (Give name of Cemetery),


Cheliusfind Center Cemetery


Hatten Perhar


on Mich. 4


190/


Dated at.


Chelmsford Mar.


· Signature and


place of business


of Undertaker.


Chelmsford


PHYSICIAN'S CERTIFICATE.


Name and Age of Deceased, f


Place and Date of Death,


Primary,


Duration


14 days


Duration,


I certify that the above is true to the best of my knowledge and belief.


Signature and Residence


6.78. Chambulici


M. D.


of Certifying Physician.


Chelmsford Wass


Date of Certificate,


March 14.


190 1.


* Give also street and number, if any. t Give 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 Cause.


Countersign and transmit to the clerk of the city or town.


....


Raid Manch 4-1901


Agent of Board of Health.


died at


Chelmsford, Mais, Ma. 4 190).


Disease or Cause


of Death,#


Secondary,


Charles Sweeten


Age, 80 Y. 11 M. 9 D.


No.


RETURN OF THE DEATH


OF


at


Date,


190


Filed,


190


[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]


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 11. 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 charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordance with section 10, and return it, together with the facts required by section 1, to the board of health or to the clerk of the city or town in which the death occurred.


[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]


SECTION 1. No human body shall be buried in a city or town or removed therefrom, until a permit therefor shall have been received from the proper authorities. No such permit shall be issued until a written statement, as required by law, has been furnished, with a physician's certificate of the cause of death. When auch atatament .-


Rev


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,


Julia Sophia Rechley


Sex,


Color,


Date of Death,


April 7 1961 189 ; Age,


45


Years,


Months,


Days.


Maiden Name, { If married, widowed }


or divorced.


Husband's Name,


Single, Martied, Widowed or Divorced,


Occupation,


At home


* Residence,


( If out of town, }


( also state fully )


Chelmsford


Place of Birth,


Worcester Mass


* Place of Death, Chelmsford


Name of Father,


Joseph B Display


Birthplace of Father,


Bennington OF


Maiden Name of Mother,


Sarah P graph


Birthplace of Mother, .


Place of Interment, (Give name of Cemetery),


Dated at


Lowell


on Apr 9 1901 :


Signature and


place of business


of Undertaker.


Lowell


PHYSICIAN'S CERTIFICATE.


Name and Age of Deceasedt


Age,.


Y.


M.


D


1


Place and Date of Death,


died at


Mass. april 7th .9.01


Disease or Cause of Death, #


J


Duration of sickness,


I certify that the above is true to the best of my knowledge and belief. ..


Signature and Residence


Saward It. Chamberlain:


1.


M. D.


of Certifying Physician.


the Chelmsford Mart


Date of Certificate


apel 8th,


.1901-


* 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.


212


Charlestown muss


Cambridge Mass


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 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 charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordance with section Io, and return it, together with the facts re- quired by section I, to the board of health or to the clerk of the city or town in which the death occurred:


Rcc


FORM C.


Commonwealth of Classachusetts.


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,


may


Cook


Sex.


Color,


Date of Death, ..


Apr 6


190% ; Age, ~ Years,.


-


.. Months,


1


.. Days.


Maiden Name, { If married, widowed ) or divorced.


Husband's Name,


Single, Married, Widowed or Divorced, --- Occupation,


* Residence, § If out of town, { also state fully. §


Of Chelmsford masa


Place of Birth, Chelmsford mass


*Place of Death,


Chelmsford base.


England


Name and Birthplace of Father, Laeth E. Cook Bettham Yorkshire.


Maiden Name and Birthplace of Mother, Ellen Lee Huddersfield, England


Place of Interment, (Give name of Cemetery), A. Chelunsford Mas


Dated at N. Chelmsford


Signature and


-


Votre brasinel pr


place of business of Undertaker.


PHYSICIAN'S CERTIFICATE.


May Cook


Age, - Y. ~ M. / D.


Place and Date of Death,


died at


7. chehurford


april 7 th


190/.


Disease or Cause of Death, ± Secondary,


Infantile Duration,


Duration,


I certify that the above is true to the best of my knowledge and belief.


JE Varney


M. D.


Signature and Residence


S


of


Certifying Physician.


H. Chilenaferal


Date of Certificate,


april 7-


190/.


* Give also street and number, if any. t Give 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 Cause.


Countersign and transmit to the clerk of the city or town.


....


Agent of Board of Health.


Name and Age of Deceased, t


- Primary,


190(


213


No.


RETURN OF THE DEATH


OF


at


Date,


190


Filed,


190.


[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]


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 11. 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 charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordance with section 10, and return it, together with the facts required by section 1, to the board of health or to the clerk of the city or town in which the death occurred.


[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]


SECTION 1. No human body shall be buried in a city or town or removed therefrom, until a permit therefor shall have been received from the proper authorities. No such permit shall be issued until -a written statement, as required by law, has been furnished, with a physician's certificate of the cause of death. When such statement and certificate are delivered to the Board of Health, the board or agent shall forthwith countersign and transmit the same to the clerk of the city or town for registration.


SECTION 5. Penalty for violation not exceeding fifty dollars.


P


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,


Magn


Sex,


male


Color,


Date of Death,


1901; Age, 30 Years,


Months,


21 Days.


1


{ If married, widowed į


Maiden Name,


or divorced.


Husband's Name,


Single, Married, Widowed or Divorced,,


Married Oco


Laborer


{ If out of town, 7


*Residence, ¡also state fully. §


Chelmsford Mass


Place of Birth,


Canada


* Place of Death,


Chelmsford Mass


Name of Father,


Quésime Jagnon


Birthplace of Father,


Lavado


Maiden Name of Mother, Corey Daily


Birthplace of Mother,


Elpanada


Place of Interment, (Give name of Cemetery),


St. Joseph Cemetine


Dated at


Lowell Mass


011.


April 2


907


Signature and place of business of Undertaker. '


Joseph Albert


#54 Echever


PHYSICIAN'S CERTIFICATE.


Name and Age of Deceasedt


Ion. Age, 35


.M.


D.


Place and Date of Death,


Disease or Cause of Death, #


Disk


Duration of Sickness,


I certify that the above is true to the best of ily knowledge and belief.




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