USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1902-1903 > Part 15
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Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
Alcal dia, 18-2-3
Rel
Chin harsh
Age, 71 8. 4 M. 7D.
No.
RETURN OF THE DEATH
OF
at
Datc, -.
190
Filed,
190 ..
[EXTRACTS FROM CHAPTER 29, REVISED LAWS.]
SECTION 6. Every householder in whosc 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 cer- 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 reecived. 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.
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.)
Date of Death,
1903.
Full Name of Deceased,
Maiden Name,
Te a married or divorced woman or a widow give also Name of Husband,
Sex, Male Color,
Single, Married, Widowed or Divoreed,
Age, 10 Years,
4 Months, 24 Days. Occupation,
* Residence { If out of town, ) { also state fully. }
Place of Death, 40, Chelmsford
Place of Birth,
Maine
Name and Birthplace of Father, Ebez Lumbert- maine
Maiden Name and Birthplace of Mother, .... Sarah Paine Manuel
Place of Burial (Give name of Cemetery),
Siste Country
Dated at 110 Chelmsford
Signature and
on
May 22 nd
1903
place of business
of Undertaker.
PHYSICIAN'S CERTIFICATE.
Peter Zumbest.
Age,
70 8
M.
D.
Place and Date of Death,
died at
North Chelwoofer
May 21
1903.
Disease or Cause of Death, ;
Primary, Immediate,
Duration,
I certify that the above is true to the best of my knowledge and belief.
JEVanner
Signature and Residence of Certifying Physician.
north Cheleangen
M. D.
Date of Certificate,
may 22
1903
* Give also street and number, if any. ¡ Give sex of infant not named. If still-born, so state.
t 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.
B
Agent of Board of Health.
Name and Age of Deceased, t
wecare of Heart-
Duration,
sudden
121
Rec
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 cer- 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.
122
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, Joseph albani
allard
Sale Color: White
Date of Death ...
1903; Age, /
.. Years, - .. Months, 4 Days.
Maiden Name,
If marfied. widowed }
ot divorced
Husband's Name,
Single, Married, Widowed or Divorced,
Occupation,
* Residence
[ If out of town }
[ also state fully
78 barry It- forall mais
Place of Birth,
78 Garry DE Rowell Mask
* Place of Death,
Name of Father,
Edward allard
Birthplace of Father,
Canada
Maiden Name of Mother,
Birthplace of Mother,
Canada
Place of Interment, (Give name of cemetery)
St. Patrick Courtry
Dated
Lowell Mass
on
Away 24
1903
Signature and
place of business
1516 REEVER MI-
of Undertaker
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
South alla
Age,
Y
. IM SAD.
Place and Date of Death,
died at
Lowell
May 24 1903.
-
Primary,
Whooping Cough
Duration,
3 weeks
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S
of
Certifying Physician.
7. Chiliutan
Date of Certificate,
May 250
190 3
* Give also street and number, if any. | Give sex of infant not named. If still-born, so state.
t 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.
1
JE Valley
M. D.
Disease or Cause of Death,#
Immediate,
FORM C.
F
No
RETURN OF THE DEATH OF
at
t Date
ate, I Filcd
[Exiled, I
SECTION 6. Every householder in v city or town in which the death occurs, shal or to the town clerk.
SECTION 7. The commanding offic board of health or to the clerk of the city SECTION 8. Penalty for neglect to ( SECTION 10. A physician shall fort request of an undertaker or other authoriz
Acts of 1897, Chapter 444. TRACTS FROM SECTIONS 6, 7, 8, 10, 11 AND 12.]
a certificate setting forth the required facts, in whose house a death occurs, the oldest person next of kin present at the time of SECTION 11. If the deceased was a De
" person in charge of an institution in which a death occurs, shall, within five days after the secondary or immediate cause of death ereof to the board of health or to the clerk of the city or town in which the death SECTION 12. Every undertaker or c tificate required by section 10, enter thereorofficer of a vessel shall give notice of the death of any person under his charge to the of the city or town in which the death ocdty or town within the Commonwealth at which the vessel first arrives after such death. It to comply with the requirements of sections 6 and 7, five dollars.
twenty-five cents.
- has attended a person during his last illness shall forthwith after the death of said LE ration a certificate setting forth the required facts.
SECTION 38. No undertaker or othsed was a soldier who served in the war of the rebellion, give both the primary and body which has not been buried, until a perath as nearly as he can state the same. Penalty for refusal or neglect, ten dollars. be issued until there shall have been delivag charge of the funereal rites preliminary to the interment of a human body shall physician's certificate of the cause of death. In accordance with section to, and return it, together with the facts required by sec- with countersign and transmit it to the clerk clerk of the city or town in which the death occurred.
123 /
FORM C.
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,
Cheney.
Se Male Color, white
Date of Death
may
24 190 3; Age, 64 Years,
/
Months,
8
Days.
Maiden Name,
( If married. widowed }
or divorced
Husband's Name,
Single, Married, Widowed or Divorced,
married Occupation,
Retired
* Residence
( If out of town
{ also state fully §
Chelmsford Mass
Place of Birth,
Bradford n. H.
* Place of Death,
Chelmsford Mano
Name of Father,
Joseph Cheney
Birthplace of Father,
acivita
Maiden Name of Mother,
Emeline Renner
Birthplace of. Mother,
Fanador
7.2. 0
Place of Interment,
(Give name of cemetery)
Claremont n. f.
Dated at
forwell
Signature and
b. In. Grung the
33 Prescott Of
on.
may 25.1903
of Undertaker
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
Sia Q. Cheney
Age, 64Y, / M, 8 D.
Place and Date of Death,
Disease or Cause of Death, #
May 24 903
dias abscess.
Duration of Sickness.
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
( Imara toward ..
M. D.
of
Certifying Physician
Date of Certificate
Mar 20
1903
Agent Board of Health.
*Give also street and number, if any. tGive sex of infant not unmed. 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
Commonwealth of Massachusetts.
place of business
died at
Chelmsford
.......
No.
RETURN OF THE DEATH
OF
at
I
Date,
...
Filed,
I
Y
Acts of 1897, Chapter 444. [EXTRACTS FROM SECTIONS 6, 7, 8, 10, 11 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 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 obrain the ;. ysician'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 of it ... which the death ou urred.
200
124
Commonwealth of Massachusetts.
[ACTS OF 1897, CHAP. 444.]
SECTION 13. The clerk of each eity and town shall forthwith make certified copies of the records of all births and deaths recorded in the books of said city or town during the previous month, whenever the deceased person or the parents of the child born were resident in any other city or town in this Commonwealth or any other state at the time of said birth or death; and shall transmit said certified copies to the clerk of the city or town in which such deceased person or parents were resident at the time of said birth or death, stating in addition the name of the street and number of the house, if any, where such deceased person or parents so residcd, whenever the same can be ascertained; and the clerk of every city or town in this Commonwealth so receiving such certified copies, or certified copies of births, deaths or marriages, from the clerk of a city or town without the Commonwealth, shall record the same in the books kept for recording births, deaths or marriages.
Blank to be used in compliance with the foregoing. (FILL OUT WITH INK, ALL NAMES TO BE IN FULL.)
Copy of the Record of a
DEATH
recorded in the books of the. City of Lowell
(City or Town.)
during the month of.
May 1903
1899.
1. Date of Death, .
may 23, 1903
2. Name,
Mary Rogan
(Maiden Name), . (Name of Husband),
mary Mi Jeaque
John & Wagon
3. Sex and Color, . .
temale White
married
4. Single, Married, Wid- owed or Divorced,
5. Age, 30 .Years, Months, Days.
Disease or Cause of Death,
Gangquenous appendicitis my days
6. {Duration of Sickness, By whom certified,.
I arthur lage m. D.
Gay It no Chelmsford, mass
7. Residence,
at Home
8. Occupation, .
9. Place of Death, .
Lowell General Hospital
10. Place of Birth,
not known
11. Name of Father,
michael m' Jeaque
not know-
12. Name of Mother, (Maiden Name.)
13. Birthplace of Father, .
14. Birthplace of Mother, .
11
St Patrick Cemetery Lowell Mars
15. Place of Interment, .
(Name of Cemetery.)
I certify that the foregoing is a true copy.
Attest : Girard @.Vadman City Clerk.
May 29, 19.03.189.
(City or Town.)
11
No.
COPY OF A RECORD
OF THE DEATH OF
....
....
which occurred in the
(City or town.) of
1899. .....
Filed
1899.
Lee
123
FORM C.
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH To the Clerk of the City or Town in which the death occurred.
(PILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name, .
Kane alefina In Mullan Sex, Le
Color,
Date of Death Alfa 29
.1993+
Age, ............ Years,
/Months,
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 }
South Chrisfand
Place of Birth,
* Place of Death,
Damil MCMullan
Birthplace of Father,
Cand
Maiden Name of Mother,
Birthplace of Mother,
Canada
Place of Interment,
(Give name of cemetery)
Dated at
Kan 29, 913
place of business of Undertaker
Archambault
735 merrick
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
Place and Date of Death,
died at
North Sachantand May 29
Disease or Cause of Death, #
Branche-Juneumenia
Duration of Sickness.
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence 1
of
1
Herch Cheburger
Date of Certificate
may 30
.1903
7E Jamney
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.
May 31
M. D.
Certifying Physician
Signature and
on
Rase a Mc Mullan Age,
Y, 10 M, D
Name of Father,
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 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.
126
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH. To the Clerk of the City or Town in which the death occurred.
Date of Death, "FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Full Name of Deceased,
Maiden Name, ...
If a married or divorced woman or a widow give also
Name of Husband,
Sex, Male Color,
Single, Married, Widowed or Divorced,
Age,~ Years, - Months,
Days. Occupation,
* Residence (If out of town, { ( also state fully. ]
Place of Death,
To, Chelems ford
Place of Birth,
Name and Birthplace of Father, Patrick Mung wat rost
Maiden Name and Birthplace of Mother, sellit. Gardy Ireland
Place of Burial (Give namc of Cemetery),
Dated at Chelmsford
on June 5 1903
Signature and place of business of Undertaker.
Patrick Mungovan
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Mungovan Age,
Y. M. D.
Place and Date of Death,
died at
190-3
-
Primary,
Infantile Duration,
Disease or Cause of Death, į Immediate,
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence ace F. E. Valucy M. D. of
Certifying Physician.
Date of Certificate, 190 0
· 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.
Lowell
Rec FORM C.
190
5 minutes
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, cause notice thercof 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 S. 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 deccased 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 cer- 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 fec 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.
2
127 R
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.)
Date of Death, de the
190 3
Full Name of Deceased,
Marie
Gauthier
Maiden Name,
If a married or divorced woman or a widow give also Name of Husband,
Sex, Color,
Single, Married, Widowed or Divorced,
Age, ..... ..... ..... Years,
Months,
_ _ Day's.
Occupation,
* Residence
( If out of town, }
{ also state fully. § North Chelmsford har
Place of Death,
Place of Birth, LL
1℃
Name and Birthplace of Father, Napoleon Gauthier
Canada
2
Maiden Name and Birthplace of Mother, Gamma Lemay leanada
Place of Burial (Give name of Cemetery)
It Couph
Dated at
Lowell Mass
Signature and
June 14 Th 1903 on
place of business of Undertaker.
Joseph Gilbert 57 Cheever LL
PHYSICIAN'S CERTIFICATE.
few hours
Name and Age of Deceased, f
mary Gauthier
Age,
D.
Place and Date of Death,
died at The Chelmsford
June 13
190 3.
Duration,
few hours
Duration,
I certify that the above is true to the best of my knowledge and belief.
es Ce Harlow
M. D.
Date of Certificate,
June 14
1903.
* 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Rical June 15 3
Agent of Board of Health.
)
1
-
Primary,
Disease or Cause of Death, Immediate,
Signature and Residence of Certifying Physician.
Ree
No.
1
RETURN OF THE DEATH
OF
at
Date,
190
Filed, 190 ..
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
1.
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 oceurs, 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 elerk of the city or town within the Commonwealth at which his vessel first arrives after such death. SECTION 8. Penalty for negleet 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 negleet, ten dollars.
SECTION 12. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's cer- tifieate required by section 10, enter thereon the facts required by section 1, and return it to the board of health or to the elerk 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.]
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