USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1902-1903 > Part 17
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Name of Father,
Birthplace of Father,
Unknown
Maiden Name of Mother,. .
Birthplace of Mother,
Ir Joseph Cemetery.
Dated at Lowell mass
Signature and
Joseph albert
on
aug 11
1983
place of business
of Undertaker
#57 Cheever St
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
Place and Date of Death,
died at. HichelmostFil, "Means. Ung 11, 902.
Disease or Cause of Death, ¿
Sen. Means.
Duration of Sickness.
I certify that the above is true to the best of my knowledge and belief.
Huthur D. Scotoria, .M. D.
Signature and Residenee S . of
Certifying Physician
Cchiline - 31 Mars",
Date of certificate Una, 12, 1903
Agent Board of Health.
*Give also street and number, if any. +Give sex of infant not named. If still-born, so state. If ehild died immediately after birth, so state. #If a Soldier or Sailor in the war of the Rebellion, give both Primary and Secondary Cause.
13
Age, 62 Y, 10 M. D.
Place of Interment,
(Give name of cemetery)
Joseph Inay
No.
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 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 sh 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
1 . ath occurred. 1:42
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,
Sex, Color, ...........
Date of Death
190 3; Age, .
Years,
4 Months,
Days.
Maiden Name, ( If married. widowed ]
or divorced
Husband's Name,
Single, Married, Widowed or Divorced,
Occupation,
North Chelmsford
*Residence
{ If out of town }
¿ also state fully §
Place of Birth,
*Place of Death,
Name of Father,
North Chelmsford
Birthplace of Father,
Rose a Potambrick
Birthplace of Mother,
nale Mass ISatracts Cometiny twee Mas.
Place of Interment,
(Give name of cemetery)
Dated at
place of business
011
Aug 11
1 900
of Undertaker
169 Worthen D.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
Helen & Hard
Age, Y, 4 M, ..... .D.
Place and Date of Death,
died at
North Cruelstory aug 11
1903
Disease or Cause of Death,
Meningitis
Duration of Sickness.
one word
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence (
JE Varney
M. D.
of
Horthy Chelun 2005
Certifying Physician
Date of Certificate
weg 12
1943
Agent Board of Health.
*Give also street and number, if any. +Glve sex of infant not named. If stili-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.
Red any
136
ela farage
Signature and
Maiden Name of Mother,
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.
Rec 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,
Phena Maria Sloan
Sex, Finale Color, Limite
Date of Death, august 12 190 3; Age, 65 Years, Months, 14 Days.
Maiden Name, If married, widowed { Phena Maria Pinney- Widowed
Husband's Name, Samuel Slan
Single, Married, Widowed or Divorced, Widowed Occupation, Sived at home
*Residence, { If out of town, ) South Chelmsford, Mass.
¿ also state fully. 3
Place of Birth, 11
11
*Place of Death, 11
Name and Birthplace of Father, alden Pinney, Vermont
Maiden Name and Birthplace of Mother, Martha Robbins-So. Chelmsford.
Place of Interment, (Give name of Cemetery), Start Pond Cemetery
Dated at So. Chelmsford,
Signature and
-
Daniel Y Bryan,
on
august 12,
1903
3
place of business
of Undertaker.
South Chelmsford Mass.
. B.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Theca Maria Sloan
65 %
Age,.
M /4 D.
Place and Date of Death,
died at.
SaChelmsford, Tiens,
M4.12 190 3.
Chronic Meningitis-Intucular Duration,
1/2 yrs.
Disease or Cause { Primary, of Death, ± Secondary,
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S of Certifying Physician.
So.Chelmsford, mark.
Date of Certificate, Ang. 13.
1903.
* Give also street and number, if any. t Givo 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
1 13
Arthur . Sartoria,
M. D.
or divorced.
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 thealth 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 becn 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.
FORM C.
Ree No.
Commonwealth of Massachusetts.
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 . Shields
Sex,
Color,
Date of Death Cinq
18 1903; Age, 22 Years,
- Months,~ Days.
Maiden Name,
§ If married, widowed {
or divorced
Husband's Name,
Single, Married, Widowed, or Divorced,
Occupation,
at Home
*Residence
S If out of town }
¿ also state fully $
North Chemsford
North Chemsford
Place of Birth,
*Place of Death,
North Chemford
Name of Father,
John Shields
Birthplace of Father,
Ireland
Maiden Name of Mother,
alice Carrot
Birthplace of Mother, Ireland
Place of Interment,
(Give name of cemetery)
SX Patrick
Dated at
Lowell, Mass
Signature and
place of business
on
aug 18 903
of Undertaker
70 y orham Sy
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
alice & Shields
Age, 22Y,
.M,
D.
Place and Date of Death,
died at
North Chelmsford Que 18
Disease or Cause of Death, #
I 903
Pulmonary Tuber culatio
Duration of Sickness.
one year
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence ( .. of
7E Jamey
M. D.
Certifying Physician
H. Chiliens
Date of certificate
Cung 18
19€ 3
Agent Board of Health.
*Give also street and number, if any.
IGive 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.
138
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 sh 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.
C-C 4043
free
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,
2 Otherland Sex timmar Color
Date of Death
Ning 18:
190 ; Age, 5%
.Years,
9
Months,
18 Days.
Maiden Name,
{ If married. widowed }
Maggie Teaser
or divorced
Husband's Name,
Hector Sutherland
Single, Married, Widowed or Divorced,
Prawie Occupation,
at home
*Residence
§ If out of town [
[ also state fully }
least Chelmsford Gia cham the
Place of Birth,
Manascatia
# Place of Death,
Gast tehelmet:
Gacham 25
Name of Father,
trazer
Birthplace of Father,
A curascotia
Maiden Name of Mother,
Filoso Ma Kenzie
Birthplace of Mother,
Nova Saatin
Place of Interment, (Give name of cemetery)
Signature and
Dated at ...
18/2009
1503
place of business
011.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased; Maggie Sutherland Age. 14 Y. 9 M, 15 D.
Place and Date of Death,
died at
Carcinoma of Stomach
£
Chronic
Disease or Cause of Death,
Laplanta will Cystite Cm 28 - 1903.
Duration of Sickness.
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
un h. Fraser
M. D.
of Certifying Physician 10 Deer Park, West Ryon Mars
Date of Certificate
Cung 18-
1903
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.
Reid avec, 19-
of Undertaker
199 Decreati
139
Commonwealth of Massachusetts.
No ..
RETURN OF THE DEATH
OF
at
Date,
I
F 1
I
Filed,
1
-
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 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 :
tion I, to the board of health or to the clerk of the city or town in .
FORM.O.
No.
Commonwealth of Massachusetts. 140
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,
aug. 27
1903.
Full Name of Deceased,
Wealthy Emma Jane Hutchins
or divorced
-
Maiden Name,
Rugg
woman or a widow give also
Name of Husband,
Matthias Hutchins
Sex,
Color,
W.
Single, Married, Widowed or Divorced, ..
Widow
Age, 84 Years, Months, Days. Occupation,
* Residence
{ If out of town, }
[ also state fully. )
Chelmsford
Place of Death,
Place of Birth,
Canada
Name and Birthplace of Father,
David Rugg Springfield Wars.
Maiden Name and Birthplace of Mother,
Place of Burial (Give name of Cemetery),
Sreens Cemetery Carlisle
Dated at
Chelmsford
Signature and
3
Walter Parham
on
aug 28
1903
place of business
of Undertaker.
Chelmsford
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Wealthy Enqua have Hutchins
Age,. 8/8 D.
Place and Date of Death,
Primary,
Disease or Cause
of Death, #
Immediate,
Duration,
I certify that the above is true to the best of my knowledge and belief.
Auchun M. Acolonia,
Signature and Residence S
of
Certifying Physician.
Chelustral, man.
M. D.
Date of Certificate,
190 3.
* 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.
Agent of Board of Health.
Read This ??
died at
Enteritis
Duration,
aug. 27, 1903.
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 thereor 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.
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,
Terence ME leave
Sex,
Color,
Date of Death Aug. 29.
190 3; Age, ..... Years,
Months,
Days.
Maiden Name,
§ If married, widowed }
or divorced
5
Husband's Name,
Single, Married, Widowed, or Divorced,
.Occupation,
Laboren
*Residence
§ If out of town }
? also state fully S
North Chelunsford Muss.
Place of Birth,
Theland
*Place of Death,
North Cheleurford Muss.
Name of Father,
Terence IM late
Birthplace of Father,
not Know
Birthplace of Mother,
...........
ST Patriles
Place of Interment,
(Give name of cemetery)
Dated atC
drill Mass
Signature and
H: ON ormal Sous.
on Aug. 29
1913.
of Undertaker
322, Markt St
PHYSICIAN'S CERTIFICATE.
vence M= Cabe
Age,
65 %,
M.
D.
Place and Date of Death,
died at
North Chelmsford aug 29
1903
Disease or Cause of Death, #
Brights Disease
Duration of Sickness.
one year
I certify that the above is true to the best of my knowledge and belief.
JEVarney
M. D.
?
Certifying Physician
North Chileno texel
Date of certificate
aug 30
1903
Agent Board of Health.
*Give also street and number, if any.
IGive scx of infant not named. If still-born, so state. If ehild died immediately after birth, so state. #If a Soldier or Sailor in the war of the Rebellion, give both Primary and Secondary Cause.
Recicl Sehr-1
1
141
Name and Age of Deceasedt
Maiden Name of Mother,
place of business
Signature and Residence S. of
No. RETURN OF THE DEATH
OF
1
at
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 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 sh obtain the physician's certificate made in accordance with section Io, 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.
C-C 4042
142
Rec
FORM C.
Commonwealth of Massachusetts. R
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,
Elisa Brown
Sex,
Color,
Date of Death ..
31
190 3 Age, 10
Years,
3
Months, TS Days.
Maiden Name, 2 or divorced 5
{ If married widowed ?
Eliza Baker
Husband's Name,
Single, Married, Widowed, or Divorced, .. Massa Occupation,
*Residence S If out of town } also state fully S
So Chensford
Place of Birth,
Whatibarvu / M
*Place of Death,
Name of Father, Willian Baker
Birthplace of Father,
England
Maiden Name of Mother, Surah
Baker
Birthplace of Mother, England
Place of Interment,
(Give name of cemetery)
Fulton A.M.
Dated at Jamel& Maxi
place of business
on
Signature and
Jakn & Nembed
Frami
of Undertaker
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
Eliza Brown Age,
Y,
.M,
D.
Place and Date of Death,
Disease or Cause of Death, #
tênis. edités
Duration of Sickness. ten days
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S
of
Certifying Physician
Date of certificate
aug 21
1903
Agent Board of Health.
*Give also street and number, if any.
IGive scx 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.
Recy Ling. 31
1 1
sandallee
died at Und Chilisdiã Aug 31
M. D.
1
No.
RETURN OF THE DEATH
OF
.
at
Date,
I
Filed,
I
1
Acts of 1897, Chapter 444. [EXTRACTS FROM SECTIONS 6, 7, 8, 10, II AND 12.]
1
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, shhll, 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 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.
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