USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1902-1903 > Part 12
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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.)
Date of Death, Jan 28
1903.
Full Name of Deceased, Elbridge G. Smith
Maiden Name,.
If a married or divorced woman or a widow give also Name of Husband,
Sex. m Color, Single, Married, Widowed or Divorced, Witowed
Age,. 69 Years, Months, 25 Days. Occupation, Retired
* Residence { also state fully. ) { If out of town, } Chehrsford, made.
Place of Death, Chelmsford, Marc.
Place of Birth, Westford, Mass.
Name and Birthplace of Father Why E. Smith Maine
Maiden Name and Birthplace of Mother, Dorcas Dutton Cheiroford
Place of Burial (Give name of Cemetery)
forefathers Cem. Chelmsford, Mark
Dated
Clicknoford, Mass
Signature and
Walter Perhaus
on
Jan. 28.
190 3
place of business
of Undertaker.
Chelmsford
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Place and Date of Death,
Primary, -
Disease or Cause of Death, Immediate,
Elfriday S. Smith Age, 69 8.9 M. 2UD.
died at.
Chibreford
JAN. 2.2 "1903.
Bright Disease
Duration,
2. Teamo
Praemie Poisoning
Duration,
I certify that the above is true to the best of my knowledge and belief.
M. D.
Signature and Residence S of Certifying Physician.
Date of Certificate, 2.9 1903.
* Give also street and number, if any. f 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
No.
RETURN OF THE DEATH
OF
at
.....
... .
Date, -.
.190
Filed,
190 ..
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose house a death occurs and the oldest next of kin of a deceased person in the city or town in which the death occurs, shall, within five days thereafter, canse notice thereof to be given to the board of health or to the town clerk.
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 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 certificate setting forth the required facts.
SECTION 11. If the deceased was a soldier or sailor 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. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's cor- tificate required by section 10, enter thereon the facts required by section 1, and return it to the board of health or to the clerk of the city or town in which the death occurred. The person making such return shall receive from the city or town a fee of twenty-five cents.
[EXTRACTS FROM CHAPTER 78, REVISED LAWS.]
SECTION 38. No undertaker or other person shall bury a human body in a city, or town or remove therefrom a human body which has not been buried, until a permit from the board of health or its agent has been received. No such permit shall be issued until there shall have been delivered to such l a written Lent, containing the facts required by law, with a physician's certificate of the cause of death. The Board of ch or ager ·ceipt of such statement and certificate, shall forth- with countersign and transmit it to the clerk of the city or \. wn for re
Penalty for violation not exceeding fifty dollars.
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,
moore
Sex, Jemal Color,
Date of Death
903; Age,.
Years, Months, Days.
Maiden Name, 1 or divorced
Husband's Name,
Single, Married, Widowed or Divorced, Occupation,
* Residence ( If out of town { ¿ also state fully }
Place of Birth,
*Place of Death,
16
1.1
Name of Father,
North of Ireland
Maiden Name of Mother, Mary Smith
Birthplace of Mother,
Place of Interment, (give name of cemetery)
Dated at no Chilispor !!
Signature and
James S. Sto Thew
place of business
on
May 31 20 1903
of Undertaker
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt'
Age, ~ Y, ~M, ~ D.
Place and Date of Death,
died at north Chiles fent any 30- 1903
Disease or Cause of Death, #
still born
Duration of Sickness.
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence M. D.
of
Certifying Physician.
Date of Certificate. Jamy 31 1908
Agent Board of Health.
*Give also street and number, if any.
tGive 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.
9
{ If married, widowed ?
noone
Birthplace of Father,
Moore
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 the 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 charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certifi(. I return it, together with the facts required-soft ion I, to the board the death occurred.
Res FORM C.
Commonwealth of Classachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death,
Leb. 5,
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
1903.
Full Name of Deceased, Samuel L. Garland
Maiden Name,
woman or a widow give also ( : a married or divorced
Name of Husband,
Sex, .
Color,
20
Single, Married, Widowed or Divorced,
Mariech
Age,. 66 Years, Months, 18 Days. Occupation, Retirech
* Residence
{ also state fully. §
{ If out of town, } South Chelmsford mass
Place of Death,
Place of Birth,
Topsham UL.
Name and Birthplace of Father. pri amos Garland Ossipee, D. H.
Maiden Name and Birthplace of Mother, Betsey Parker, Salisbury, n. H.
Place of Burial (Give name of Cemetery),
Hast Pond Century
Dated at
+ Chelmefont, Mais.
Signature and
Walter perfil
on
Lieb. 6
190 3
place of business -
of Undertaker.
Chelmsford
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Place and Date of Death,
Primary,
Straat Disney Duration,
Disease or Cause
of Death, ţ
Immediate,
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence § of Certifying Physician.
Atu D. Acoboria
M. D.
Chelmsford, mais.
Date of Certificate,
Fik. 6
190 3.
* Give also street and number, if any. | 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
100
Sanif. L. Parland.
Age, ..
68 8./ M. I& D.
died at
So. Chelmsford, mass.,
Feb. 5, 1903.
No.
RETURN OF THE DEATH
OF
at
Dato,.
190
Filed,
190
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose house a death occurs and the oldest next of kin of a deceased person in the city or town in which the death occurs, shall, within five days thereafter, cause notice thereof to be given to the board of health or to the town clerk.
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 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 certificate setting forth the required facts.
SECTION 11. If the deceased was a soldier or sailor 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. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's cor- tificate required by section 10, enter thereon the facts required by section 1, and return it to the board of health or to the clerk of the city or town in which the death occurred. The person making such return shall receive from the city or town a fee of twenty-five cents.
[EXTRACTS FROM CHAPTER 78, REVISED LAWS.]
SECTION 38. No undertaker or other person shall bury a human body in a city, or town or remove therefrom a human body which has not been buried, until a permit from the board of health or its agent has been received. No such permit shall be issued until there shall have been delivered to such board a written statement, containing the facts required by law, with a physician's certificate of the cause of death. The Board of Health or agent, upon receipt of such statement and certificate, shall forth- with countersign and transmit it to the clerk of the city or town for registration. Penalty for violation not exceeding fifty dollars.
Rec
FORM C.
Commonwealth of Massachusetts.
10%
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,
Bridget Ready
Sex,
Color,
Date of Death
Feb 9
1903; Age, 66
Years,
.Months,
-Days.
Maiden Name,
{ If married. widowed )
or divorced
Husband's Name,
Micheal Ready
Single, Married, Widowed or Divorced,
Occupation,
at Home.
*Residence
S If out of town }
North Chemsind
falso state fully §
Place of Birth,
Ireland
*Place of Death,
North chelmsford
Name of Father,
Michael Ready John McKoen
Birthplace of Father,
Ireland
Maiden Name of Mother,
Bridget Someone
Birthplace of Mother,
Ireland
Place of Interment,
(Give name of cemetery)
It Patrick
Dated at.
Lowell
Signature and
place of business
on
Liebe 9
1903
of Undertaker
1
Moyenhamsh
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
Place and Date of Death,
Disease or Cause of Death, #
Influenza
Duration of Sickness.
Four days
I certify that the above is true to the best of my knowledge and belief.
JE Varney
Signature and Residence
1
of
north chilean find
Certifying Physician
Date of Certificate
Jibi 9
1903
Agent Board of Health.
*Give also street and number, if any. +Give sex of infant not named. If still-born, so state If child died immediately after birthi, so state. #If a Soldier or Sailor In the War of the Rebellion, give both Primary and Secondary Cause.
Read thex 10
Bridget- Ready
Age,
66 %,
M,
.D.
died at
north Chelineford
1903
M. 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 occured.
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 the 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 a's 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 interinent of a human body shall obtain the physician's certificate made in accordance with section to, and return it, together with the facts required by sec- tion 1, to the board of health or to the clerk of the city or town in which the death occurred.
A
FORM C.
Commonwealth of Massachusetts.
No
RETURN OF A DEATH To the Clerk of the City or Town in which the death occurred.
,Name,
HenryMénard
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Sex
Inale
Color,
Date of Death
Feb. 20
190 2, Age, 60 Years.
. Years,
.. Months.
20 Days.
Maiden Name,
{ If married. widowed }
, or divorced
Husband's Name,
Single, Married, Widowed or' Divorced,
Occupation,
** Residence
in North Chelmsford Wass
{ also state fully )
Canada
Place of Birth,
* Place.of: Death;
I North Chelmsford.
Name of Father,
noël Menard
Birthplace of Father,
Canada
Maiden Name of Mother Mary Anknown
Birthplace of Mother,
Canada
Place of· Interment,
(Give name of cemetery)
It Joseph Cemetery -
Dat Lowell Mass
Signature and
Joseph Albert
8 20th
1
963
place of business
1 011
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
Jerry Ménard
Age,
60 8, 4 M, 20 D.
Place and Date of Death,
Disease or Cause of Death, #
died at
North Chelmsford Icky 20
I
903
Cancer y Pancreas.
. Duration of Sickness.
six months
I certify that the above is true to the best of my knowledge and belief.
JE Vany
M. D.
Date of Certificate
1903
.......... Agent Board of Health.
*Give also street and number, if any. +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.
Signature and Residence of Certifying Physician
1
of Undertaker
102
No
RETURN OF THE DEATH
OF
at
Date,
I
Filed,
I
...
F
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 occured.
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 the 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 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 sec- tion I, to the board of health or to the clerk of the city or town in which the death occurred.
Varney
A
Ree
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,.
Alice C Peterson
Sex,
Female Color,
Date of Death
Feb 27th
1903; Age, 79 Years,
8 Months, 10 Days.
Maiden Name,
{ If married, widowed }
Alice d Jurail
Husband's Name,
Jonas
or divorced
Single, Married, Widowed or Divorced,
Widow Occupation,.
House Keifer
*Residence
{ If out of town }
[ also state fully )
W Chelmsford
Place of Birth,
Serceden.
* Place of Death,
West Chelmsford
Name of Father,
Unknown
1.
Birthplace of Father,
11
Birthplace of Mother,
Place of Interment, (give name of cemetery)
west- Chelmsford
Dated at
Feb. 28# 1903
Signature and
AS Parkhurst
5
place of business
of Undertaker
IW Chelmsford
on
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
alise C Peterson
Age, 79 x 8
M, 10 D.
Place and Date of Death,
died at.
TreatChemustard
July 27 1 903
Disease or Cause of Death, #
Senility
Duration of Sickness. .
One week in bed
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
M. D.
Certifying Physician.
Date of Certificate.
.1903
Agent Board of Health.
*Give also street and number, if any.
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.
9
Maiden Name of Mother,
I
of
103
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 the 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 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 retu ogether with the facts required by sect- ion I, to the board of health or to the clerk of the city of town in which t curred.
104%
FORM C.
Commonwealth of Massachusetts.
No. .......
RETURN OF A DEATH To the Clerk of the City or Town in which the death occurred.
Name,
Jose Folundby
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Sex, Color,
Date of Death March & T
1903; Age, 34 Years,
.Months,
.. Days.
Maiden Name,
If married. widowed }
or divorced
Husband's Name,
Urdown
Single, Mawied, Widowed or Divorced,
Occupation,
at Home
*Residence
[ also state fuliy }
( If out of town }
North Bramford
Place of Birth,
* Place of Death,
North thelord Muss.
Name of Father,
Andrew leamplial
Birthplace of Father,
Tulauch
Maiden Name of Mother,
Kate Michemin.
.
Birthplace of Mother, ........
Daca Matches
Place of Interment, (Give name of cemetery)
Signature and
1. F. omul & Sons
Dated at
place of business
on
Man 9
1923.
of Undertaker
1324 Market Sh Small Mass.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased;
Place and Date of Death,
died at
north Chilena for
March 8
1803
Disease or Cause of Death, #
Pulmonary Tuberculosis
Duration of Sickness. one year
I certify. that the above is true to the best of my knowledge and belief.
Signature and Residence
DE launay
M. D.
of
1
Certifying Physician
Date of Certificate
Much 9
1903
Agent Board of Health.
*Give also street and number, if any.
+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.
Rec
Race Folliusby
Age, 34 Y,
M,
D.
No.
RETURN OF THE DEATH
OF
Jose Fallenrhy
at
Date,
March 81903
Filed,
March10, 1903
3 .
.
1
1
-
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 occured.
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 the 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 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 sec- tion 1, to the board of health or to the clerk of the city or town in which the death occurred.
105
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.)
Date of Death,
March 6th
190
Full Name of Deceased, Eva Verville
Maiden Name,
If a married or divorced woman or a widow give also
Name of Husband,
Sex,
Female Cole
Single, Married, Widowed or Divorced,
Age,
Years,
2
Months,
19
Days. Occupation,
* Residence {If out of town, ) ( also state fully. f
# North Chelmsford mass
Place of Death,
North Chelmsford Mase
Place of Birth, North Chelmsford mass
Name and Birthplace of Father, Ernest Vierville
, Canada
Maiden Name and Birthplace of Mother, Séverine Sellier Canada
Place of Burial (Give name of Cemetery It Joseph Cemetery
Dated at
Lowel Mass
Joseph Albert
on March 6th .190 3
Signature and place of business of Undertaker.
#5y Chever SV
PHYSICIAN'S CERTIFICATE.
Era Viruelle
Age,
Y. 2 M. D.
died at
Heraf Chilen Low
Mik 6'
.190 ?
Disease or Cause of Death, }
Primary, Immediate,
Duration,
I certify that the above is true to the best of my knowledge and belief.
LEJamey M. D.
Signature and Residence S of .
Certifying Physician.
71. Chitrafen
Date of Certificate, 190 3
· Give also street and number, if any. | 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
Name and Age of Deceased, ¡
Place and Date of Death,
Mannenus
Duration Sweaters
No.
RETURN OF THE DEATH
OF
at
.
Date, ...
190
Filed,
190
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose house a death occurs and the oldest next of kin of a deceased person in the city or town in which the death occurs, shall, within five days thereafter, canse notice thereof to be given to the board of health or to the town clerk.
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