USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1902-1903 > Part 18
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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 4042
143
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,"
Alfred a. Clarke
Sex,
m
Color,
20
Date of Death Stefer. 14,
1903; Age, 11
Years,
2
Months,
.Days.
Maiden Name,
" If married, widowed }
or divorced
5
Husband's Name,
Single, Married, Widowed, or Divorced, Occupation,
*Residence
§ If out of town }
¿ also state fully §
Place of Birth,
amesbury.
Mas
*Place of Death,
Chelmsford,
Name of Father,
Lewis E. Clarke
Birthplace of Father,
Dawves.
Maiden Name of Mother,.
Rose a Fimmegan.
Birthplace of Mother,
Portland te.
Place of Interment,
(Give name of cemetery)
Pine Ridge leen. Chelmsford, Mais
Dated at
chelmsford, Mais
Signature and
Walter Parham
on. Sept. 15,
place of business
Chelmsford
1903
of Undertaker
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased,*
Date and Place of Death,t - died at
Disease or Cause of Death, -
(Primary and Secondary.)}
Duration of Sickness,
-
-
I certify that the above is true, to the best of Any knowledge and belief.
Signature and Residence of Certifying Physician,
Date of Certificate,
Sept. 14,
* Or Sex of Infant (not named). If stillborn so state.
t If child died immediately after birth so state. Plate. Ed. December, 1896. - 5,000.
# If a soldier or sailor who served in the War of the Rebellion.
Roca Sch1-15
Alfrack A. Clarke
Age, 11 ant Id's.
Sept. 14, 1903 789
,
of Drowning
1903
No.
RETURN OF THE DEATH
I
I
OF
at
Date,
"Filed,
EXTRACTS FROM SECTIONS 6, 7, 8, IO, II AND 12. in whose house a death occurs, the oldest person next of kin present at the time of te person in charge of an institution in which a death occurs, shall, within five days after thereof to the board of health or to the clerk of the city or town in which the death
to comply with the requirements of sections 6 and 7, five dollars. + officer of a vessel shall give notice of the death of any person under his charge to the city or town within the Commonwealth at which the vessel first arrives after such death. has attended a person during his last illness shall forthwith after the death of said ition a certificate setting forth the required facts.
f ised was a soldier who served in the war of the rebellion, give both the primary and ath as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.
hg charge of the funereal rites preliminary to the interment of a human body sh in accordance with section 10, and return it, together with the facts required by sec-
;lerk of the city or town in which the death occurred.
C-C. 4042
Acts of 1897, Chapter 444.
uio last inness shall, when requested, forthwith furnish for regis- tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying immediately thercafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate, stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg- lects or refuses to make a certificate as aforesaid, or makes a false statement therein, ne shall be punished by a fine not exceeding fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both the primary and the secondary or immediate cause of death as nearly as he can state the same.
If a physician refuses or neglects to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.
SECTION 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same. When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall fortli- with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed- ing fifty dollars.
Rec
144
FORM C.
Commonwealth of Massachusetts.
No
RETURN OF A DEATH To the Clerk of the City or Town in which the death occurred.
Name, ..
Yvonne Verville
ALL NAMES TO BE IN FULL.)
Female Color, Ahito
Date of Death. Lept 15th
1900;
6
Age, ....
Years,
Months, .- Days.
Maiden Name,
§ If married, widowed }
or divorced
5
Husband's Name,
Single, Married, Widowed, or Diyorced,
north Chelmsford, Mass
*Residence
S If out of town ?
1
¿ also state f
Place of Birth,
North Chelmsford Mass
North Chelunsford mass.
*Place of Death,
Joseph Verville
Name of Father,
Birthplace of Father,
Canada
Maiden Name of Mother,
Dielvina Guay
Birthplace of Mother, Canada
Place of Interment,
(Give name of cemetery)
Ir Joseph Cemetery
Dated
Lowell Mass
on.
Sept 15, 903
place of business
of Undertaker
Signature and
Joseph albert
# 57 Chever
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
Yvonne Verville Are,
Y,
6 M. - D.
Place and Date of Death, died at 11. Chilienfant Jeff 15th 900
Disease or Cause of Death, #
Maras mus
Duration of Sickness.
six month
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
7 E Varney
M. D.
of
Certifying Physician
H. Chelistino
Date of certificate
421.16
1 902
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.
No.
RETURN OF THE DEATH
OF
at
Date,
T
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 4042
Chelmsford Littleton St.
ilec
FORM C.
Commonwealth of Massachusetts.
RETURN OF A DEATH To the Clerk of the City or Town in which the death occurred.
Lafortune)
Name, .
Delima Yağışlı
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Sex, ...
Color,
White
Date of Death
Sept 1$
03
Age,. Years,
Months, Days.
Maiden Name, § If married, widowed ?
or divorced
Delima Folicoeur
Husband's Name,
Edmond Lafortune
Single, Married, Widowed, or Divorced, Married Occupation, House Wife
*Residence
§ If out of town ?
Warren Cer.
Chelinsford Center, Mais
¿ also state fully s
Place of Birth,
canada
*Pace of Death,
Warren Tive Chelmsford Center Mass
folicosur
Name of Father,
Birthplace of Father,
Unknown
Maiden Name of Mother,
Birthplace of Mother,
Montreal Cemetery, Canada
Place of Interment, (Give name of cemetery)
Dated at, Lowell mass
Signature and
fraph albert
Dept 18
. 913 place of business of Undertaker
# 5M Cheever St.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceasedt
Delucia Lafortuna Age, 54%, M, .D.
Place and Date of Death,
died at
Child foral Mars, Sept. 18,
1903
Disease or Cause of Death, #
1 )
Duration of Sickness.
3 days -
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S
of Certifying Physician Cheersford, Mouse2 M. D.
Date of certificate
Sept. 18
1 903.
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 Causc.
Arthur V Scobonsa
on ..
145
No.
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 sh obtain the physician's certificate made in accordance with section IG, and return it, together with the facts required by sec- tion I, to the board of health of to the clerk of the city or town in which the death occurred.
C-C 4042
Re P
FORM G.
No.
Commonwealth of Massachusetts.
[EXTRACT FROM ACTS OF 1897, CHIAP. 444.]
SECTION 13. The clerk of each city and town shall forthwith make certified copies of the records of all * * * deaths recorded in the books of said city or town during the previous month, whenever the deceased person * * * was a
* * death; and shall resident in any other city or town in this Commonwealth or any other state at the time of said *
transmit said certified copies to the clerk of the city or town in which such deceased person *
*
was a resident at the
* * time of said * death, stating in addition the name of the street and number of the house, if any, where such deceased person * * * resided, 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 * deaths * * * from the clerk of a city or town with- out the Commonwealth, shall record the same in the books kept for recording deaths *
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 Springfield
(City or Town)
during the month of
190 3.
1. Date of Death, June 30. 1903
2. Name,
James albert Stackpole
(Maiden Name), . (Name of Husband),
3. Sex and Color, . ·
11
2/
5. Age, 56 Years,
Months, - Days.
Disease or Cause of Death,
Pneumonia 1 9 days
6. Duration of Sickness, By whom certified,.
Seo. C. Mc Clean M.D.
Chelmsford Mass.
7. Residence,
Fancy Gardenw
9. Place of Death, .
Grospeer. Dr. Springfield
10. Place of Birth, .
Dorty. n. 2.
11. Name of Father,
James Stackpole
12. Name of Mother, (Maiden Name.)
13. Birthplace of Father, .
Unknown.
14. Birthplace of Mother, .
Unknown
Edson Cemetery Lowall-
15. Place of Interment, . (Name of Cemetery.)
I certify that the foregoing is a true copy.
Attest : annie It. Hawher
acet atuClerk.
(City or Town. )
190
:
4. Single, Married, Wid- owed or Divorced,
8. Occupation, .
Marta Twombly
,46
No.
COPY OF A RECORD OF THE DEATH OF
which occurred in the
(City or town.) of ..
190
·
Filed
190
Re
147
FORM O.
Commonwealth of glassachusetts.
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,
Axel Jueron Johnson
Sex
Color,
Date of Death,
Jekl-15th C/
190 3 ; Age_Years, 3 Months, 4 Days.
Maiden Name,
§ If married, widowed }
or divorced.
Husband's Name,
Single, Married, Widowed or Divorced, Jingle
Occupation,
*Residence, { If out of town, ) ¿ also state fully. §
Place of Birth,
west Chelmsford mass
"Place of Death,
West- Chelmsford "
Name and Birthplace of Father,
Gustave Johnson Tweeden
Maiden Name and Birthplace of Mother,
Vann Freuen Jeorden
Place of Interment, (Give name of Cemetery),
West Chelmsford Hess Cem
Dated at.
West Che motores
Signature and
-
on
Tips- 16h
/190 5
place of business
of Undertaker.
West Chelmsford Man
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Cafel & Johnson
.Age,
Y. 3 M. 4 D.
Place and Date of Death,
died at
West- Chelmsford Defit-15
1903.
Sinstroke
Duration, 18 hours
aculé meningitis
Duration,
18 hours
I certify that the above is true to the best of my knowledge and belief.
I a Harlow
M. D.
Signature and Residence S of
Certifying Physician.
Tyngsboro
Date of Certificate,
Jefl-16th
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 Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
1
Disease or Cause
of Death,
Secondary,
Primary,
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 oceurs, 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 certifieate made in aeeordanee 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 oeeurred.
[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]
SECTION 1. No human body shall be buried in a eity 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 sueli 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.
Rock
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
148
RETURN OF A DEATH
FULL NAME Frank IRone
Registered No.
53
Place of Death *
Monti Chelmsford
Date of Death.
Sept-18 1903 Age 43
years ..
.months.
.days
STATISTICAL DETAILS
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
NAME OF FATHER Tarnothy Dominans
BIRTHPLACE OF FATHER#
MAIDEN NAME OF MOTHER Sarah Coyne
BIRTHPLACE OF MOTHER #
OCCUPATION
INFORMANT § If. O Sommit Sons.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Seft-16 1903 to Sept-18 1903, that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary : acculé Nephritis
(DURATION) 200 . DAYS
Contributory :
Fatty degeneration of
Yuart-
... (DURATION) ... .DAYS
(Signed)
& attarlow
M.D.
Sept-18 903 (Address).
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
.Place of Death ?.
Days
Where was disease contracted, if not at place of death ?
Filed
Saft 19 1903
€
Jour Clerk
PLACE OF BURIAL OR REMOVAL II
St Pattes lo meter mall
DATE OF BURIAL
Suffo 20
... 190.3.
UNDERTAKER
ADDRESS
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Speclai Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
# State or country ; also city, town or county, If known.
§ Name and address of person giving statistical details. If Name of cemetery.
Read Scht 19
1
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Leon Samuel Hoch
.Registered No.
54
Place of Death *
Chelmsford, Mais
Date of Death
Clef. 6.1963
Age
15
years ..
11
.months
16
days
STATISTICAL DETAILS
SEX
m.
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
9
MAIDEN NAME
HUSBAND'S NAME t
BIRTHPLACE #
Chelmsford Maso.
NAME OF
FATHER
almon W. Healt
BIRTHPLACE OF FATHER# Banger n. 4.
MAIDEN NAME
OF MOTHER
Susie Derhanc
BIRTHPLACE
OF MOTHER#
Chelmsford Mass
OCCUPATION
Student.
INFORMANT §
A.W.Halk; rather
Chelunsford.
PLACE OF BURIAL OR REMOVAL !! Forefathers Cem, Ellebistand mass.
DATE OF BURIAL
Oct, 9.
190 3
UNDERTAKER
Walter Perham
ADDRESS
Chelmsford.
PHYSICIAN'S CERTIFICATE
i HEREBY CERTIFY that i attended deceased during last illness, from ... 190 __ to: Oct. 6 190.3 .... that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
accidental asphyxiation.
(DURATION).
DAYS
Contributory :
ADURATION). DAYS
(Signed).
Imaen toward
.. M.D.
Ort, yth
190.3 ... (Address).
Chelmsford
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?...
....
.Days
Where was disease contracted,
If not at place of death ?.
2
Filed Oct, 9 .. 190.3. .. Yes, A Tarifuerst
Town Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." if in a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow. # State or country ; also city, town or county, If known.
§ Name and address of person giving statistical details. İl Name of cemetery.
Rec
149
.
150
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Stillborn
.Registered No ..
Place of Death *
Chelmsfordh Mass
Date of Death.
Det. 9, 01903
Age.
years.
.months.
days
STATISTICAL DETAILS
SEX 7
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
Chelmsford. Mass.
NAME OF FATHER Edgar F. Parkhurst
BIRTHPLACE OF FATHER# Chehusfunds Mare.
MAIDEN NAME OF MOTHER Edith" Bosca
BIRTHPLACE OF MOTHER # Rowell
OCCUPATION
INFORMANT § Natter Derham
PLACE OF BURIAL OR REMOVAL II Forefathers Ceny
DATE OF BURIAL
Oct. 9
190.
UNDERTAKER Chelmsford Masbalss Walter Perham
Chelunsford.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. 190 +0. Oct.9 .190.3 ... , that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary : Still bore
(DURATION).
DAY8
Contributory :
Chinasa Howard
.... (DURATION). . DAYS
(Signed)
v
M.D.
Art.10 - 1903 (Address).
Chilmal
SPECIAL INFORMATION only for Hospitals, Institutlons, Transients, or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?.
.. Days
Where was disease contracted, If not at place of death ?
Filed
Det 12 1908
Gro Y. Parkhurst
your Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number. t In case of married or divorced woman, or widow.
# State or country ; also city, town or county, If known.
§ Name and address of person giving statistical details. Il Name of cemetery.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
Rxw
-
COMMONWEALTH OF MASSACHUSETTS
RETURN, OF A DEATH
FULL NAME
1
Place of Death *
Laholmstout Tavo
Date of Death.
Och-
17,
903 Age 5-6
6
.years
12
.months
days
STATISTICAL DETAILS
SEX
Inale
COLOR ^
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Married
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE ± Bastare, Hlavu, .
NAME OF
FATHER
Richard Hodson
BIRTHPLACE OF FATHER# Boston.
TiLaus.
MAIDEN NAME OF MOTHER Hilary Xiricit.
BIRTHPLACE
OF MOTHER#
Boston Mars
OCCUPATION
INFORMANT §
fideu-
PLACE OF BURIAL, OR REMOVAL II
DATE OF BURIAL W. Cheiroford del 2/1 1903
UNDERTAKER ADDRESS byl. Coruna Hed 33 Prescott Name of cemetery.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Chefia 1903 to- 190 ...... , that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary: Fracture / Stacey und cassation. ") braine with Lemon hage (DURATION) .. / .. DAYS
Contributory :
(Signed)
further Tage.
M.D.
Oct 19
.. 1903 (Address) 64 Cambialky
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
How long at
Place of Death ?
.Days
Where was disease contracted, If not at place of death ?
Filed Oct-20 1903
& Parkhurst,
Town Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information," If in a Hospital or Institution, give Its NAME instead of street and number.
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