USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1902-1903 > Part 19
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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 detalls.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
15%
Registered No.
56
(DURATION). .. DAYS
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Registered No.
Place of Death *
Date of Death
Del- 29 - : 903
Age ..
. years.
.months
days
STATISTICAL DETAILS
SEX
COLOR
Female White
SINGLE, MARRIED WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # north Chelmsford
NAME OF
FATHER
Augustres ED
BIRTHPLACE OF FATHER# North Chelmsford
MAIDEN NAME
OF MOTHER
Daisy I Ripley.
BIRTHPLACE
OF MOTHER #
north Chelication
OCCUPATION
Prison Officer
INFORMANT §
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that i attended deceased during last
iliness, from ..
Cel- 29 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 :
still birth
Primary :
frammature
. (DURATION).
DAYS
Contributory :
(Signed)
JE Varney
.. (DURATION). .. DAYS
.M.D.
Del.29 1903 (Address) Ha Chehundert Meer
1 .4
SPECIAL INFORMATION only for Hospitais, institutions, Transients, or Recent Residents.
Former or Usuai Residence
How long at
Place of Death ?..
.Days
Where was disease contracted, if not at place of death ?
Filed
.190
Cierk
PLACE OF BURIAL OR REMOVAL II
UNDERTAKER 10 Chelmsford
DATE OF BURIAL
Det 29
1903
ADDRESS
* 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 ; aiso city, town or county, If known.
§ Name and address of person giving statisticai details. || Name of cemetery.
152
C
Horos Chebesten.
still own
1
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Leather Ht Sargent
.Registered No.
Place of Death *
Charth Chelmsford Mask
Date of Death.
chov 7
1903
Age
61
years
.months
.days
STATISTICAL DETAILS
SEX
AL.
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME t HUSBAND'S NAME +
BIRTHPLACE #
Canterbury Not
NAME OF
FATHER
Joshua sargent
BIRTHPLACE
OF FATHER#
London NH
MAIDEN NAME
OF MOTHER
Belinda Haines
BIRTHPLACE
OF MOTHER #
Gordon M.H,
OCCUPATION
Book Keeper
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
northo Checristina
DATE OF BURIAL
nov 10
1903
UNDERTAKER
ADDRESS
Stowell
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from.
1894
190 ..... to Nov / 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 : Brigit's Discuse
Ber 4 years
.. (DURATION) .. DAYS
Contributory :
Eratil years
.(DURATION) .. DAYS
(Signed)
.M.D.
.1903 (Address) I Chelwe ins.
SPECIAL INFORMATION only for Hospitais, 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 Nov. 9 1907 TED, A. Parkhurst Town Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Speclal 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 detalis. |/ Name of cemetery.
153
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
Rec
1075
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
I'forences tremblay
Registered No.
Place of Death *
Chelmsford Center. mass
Date of Death.
nov. 13 th 1903
.. Age
years.
9
.months .
1%
.. days
STATISTICAL DETAILS
COLOR
White
SINGLE, MARRIED, WIDOWED, OR- DIVORCED
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE #
lebelinsford mass.
NAME OF
FATHER,
Jules Tremblay
BIRTHPLACE
OF FATHER#
Canada
MAIDEN NAME
OF MOTHER
Cena Fortino
BIRTHPLACE
OF MOTHER #
Canada
OCCUPATION
INFORMANT § Sales Tremblay
PLACE OF BURIAL OR REMOVAL II Ir Joseplu @ mistery
DATE OF BURIAL DAN. 14 903
UNDERTAKER sph albert
ADDRESS
57 Cheever
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from .. Mon, 10th 1903 to Only / Misil 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 :
Pestro
... (DURATION).
30
. DAYS
Contributory :
milk
(DURATION). DAYS
(Signed).
9 . H. 1 day
M.D.
Nov . 13 903 (Address) 139 Merrimack IL
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
Place of Death 7.
Days
Where was disease contracted, If not at place of death ?.
Filed Nov, 13 1903
Cour 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. || Name of cemetery.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
/
Enterit
1
1
3
L
பரிசந்திரப்பார்க்கம் -துருமோடி -
Rai
- MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Clara et Salmon
Registered No.
60
Place of Death *
Non 14 21 1903
Date of Death ..
No telefone Age 34
.. years.
8
.months
12
days
STATISTICAL DETAILS
SEX Female
COLOR
white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Canned
MAIDEN NAME Chana Ct Satyan
HUSBAND'S NAME + frederick &Sahn
BIRTHPLACE #
NAME OF FATHER
Sammel T. Wright
BIRTHPLACE OF FATHER# Westford
MAIDEN NAME OF MOTHER
BIRTHPLACE
OF MOTHER±
Dunstable
OCCUPATION
INFORMANT § Kredinich & Sahun
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. 7'00 73 1903 to Play 15 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 :
Prunmarin
.(DURATION).
8
. DAYS
Contributory :
(Signed)
JE Varney
M.D.
.1903 (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 Wow, 17 1903 fro. M. Parkhurst Jour 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. NI Name of cemetery.
Abad Min. 17
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
Nov 18
190 3
UNDERTAKER Act Wembed
ADDRESS
155
... (DURATION), DAYS
1
PVE HTIV
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
John,
yaw
Registered No. ......
Place of Death
Date of Death
IN 22d. 1903
Age ...
.. years ..
.months
.days
STATISTICAL DETAILS
SEX
male
2
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME t'
HUSBAND'S NAME +
BIRTHPLACE Duland
NAME OF
FATHER
John Jyan
BIRTHPLACE OF FATHER# Vueland
MAIDEN NAME
OF MOTHER
not known
BIRTHPLACE
OF MOTHER #
Duland
OCCUPATION Blacksmith
INFORMANT §
Joseph Ryan son,
Anth Chilens ford
DATE OF BURIAL
190 3
ADDRESS
UNDERTAKER
H. VAnwell TUmo 524 /MIN.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that i attended deceased during last
illness, from.
Mar. 22 903 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 :
Pulmonary Henconnage
death sudden
.. (DURATION).
DAYS
Contributory :
Pulmonary Intercalares
the year
.(DURATION). .. DAYS
(Signed)
F Elancy
M.D.
12 23
190 (Address).
SPECIAL INFORMATION only for Hospitais, 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 Gro & Parkhurst Cierk
* 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 detalls.
156
Ree
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVALA A Paluns unter
Arth Chileno ford
1
Rec
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
David Clinton Pertany.
Registered No.
62
Place of Death *
Chelmsford Centro
Date of Death
November 23, 1903
Age ..
73
years ..
0
.months
7
.days
STATISTICAL DETAILS
SEX
M
COLOR
W.
SINGLE MARRIED,
WIDOWED, OR
DIVORCED
Widowed
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE#
Hilton U.H.
NAME OF
FATHER
Samuel Pertam
estamy
BIRTHPLACE
OF FATHER#
Tyndeboro U.H.
MAIDEN NAME
OF MOTHER
Nichola
BIRTHPLACE
OF MOTHER #
Bedford H.
OCCUPATION
Harmer
INFORMANT § Daughter
PLACE OF BURIAL OR REMOVAL li
Do Latters Cennetin
DATE OF BURIAL
Nov 25 903.
UNDERTAKER
Walter Perkam
ADDRESS
Chekuafrod.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that i attended deceased during last iliness, from. no. 1 . 1903 to nov, 23 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 : Shock
.. (DURATION) ..
DAYS
Contributory : ....
fatter degeneration.
of heart!
8
... (DURATION) ..
.DAYS
(Signed)
amara
Howard.
M.D.
nov. 25
.190.3 ... (Address).
Chelmsford Mars
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
Nov-25
....... 190.3 ..
Go A Parthus
Jour 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. || Name of cemetery.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH Charles N. Whitman
Registered No.
63
Place of Death *
lehulmeford Maso.
Date of Death
nov. 26th 1903
.Age ..
44
years.
3
.months
days
STATISTICAL DETAILS
SEX
male
COLOR
white
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
Manchester Nova Scotia
NAME OF
FATHER
Edward N. Whitman
BIRTHPLACE
OF FATHER#
nova Scotia
MAIDEN NAME
OF MOTHER
Pantha Henderson
BIRTHPLACE
OF MOTHER#
Nova Scotia
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL II Edson Cemetery Sowell dle
DATE OF BURIAL
nov. 28
190 .. 3.
ADDRESS
UNDERTAKER
I. a. WEinbeck - Sowill Mas"
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. nov. 15 1903 to nov. 26 19031 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 :
Jaundice
1:
0
(DURATION) 12
DAYS
Contributory :
La Grippe
....
(DURATION).
4
DAYS
(Signed) ..
mara Howard.
M.D.
nov. 26 1903 (Address).
Chelmsford mars,
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 Nov, 27 1903 : Geo. A. São
Parkhauset
Jours 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. Name of cemetery.
158
Rec
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
FULL NAME
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Raymond E. Jan
Registered No.
64
Place of Death *
Chelmsford
Mass
Date of Death
por 29 0%
1903
Age ..
.years ...
3
months
.days
STATISTICAL DETAILS
SEX
male
COLOR
w
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE #
Cheever good
NAME OF
FATHER
John F. Jan
BIRTHPLACE
OF FATHER+
Wolcott, Vermont,
MAIDEN NAME
OF MOTHER
Deborale Chaufferi
BIRTHPLACE
OF MOTHER #
New Brunswick
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL II Edson
DATE OF BURIAL
Vec 1
190.
UNDERTAKER
ADDRESS
Kowill
PHYSICIAN'S CERTIFICATE
I HEREBY, CERTIFY that I attended deceased during last illness, from. Lupt 5 . 1903 to 11or 29, 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 :
Spina Bifida
3 months
.. (DURATION) ..
... DAYS
-
Contributory :
(DURATION) 9
DAYS
(Signed)
Arthur D. Acolonia.
.. M.D.
mr.30 1903 (Address).
Chelmsford, Man.
SPECIAL INFORMATION only for Hospitais, 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 Vec /
.1903 ...
Good. Parkhurst
Jowy Clerk
* Clty 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 detalis. || Name of cemetery.
159
nee
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
RETURN OF A DEATH
FULL NAME
Sarah a Humphrey
Registered No.
6.57
Place of Death *
levemetrid, mais
Date of Death
Lec 2 1903
Age.
76
. years.
... months.
.days
STATISTICAL DETAILS
SEX female
COLOR
white.
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
verdure
MAIDEN NAME +
Sarah à Cartão
HUSBAND'S NAME +
leo 8 Humphrey
BIRTHPLACE ± Enfield 7 1+
NAME OF
FATHER
Joseph learter
BIRTHPLACE
OF FATHER
unterown.
MAIDEN NAME
OF MOTHER
Elizatych Celougis
BIRTHPLACE
OF MOTHER #
OCCUPATION
at Home
INFORMANT § les Humplief
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from. no amedicação iflinedance 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 :
Senile Precumenda
one in welke
DURATION) .. DAYS
Contributory :
death dec 3d , 90,3
DURATION).
DAYS
(Signed)
M.D.
Lee 3%.
190 ... 3 (Address).
.2.
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
Nev, 3
.1903
Goo. A. Parkhurst
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 marrled or divorced woman, or widow.
# State or country ; also city, town or county, If known,
§ Name and address of person giving statistical details.
PLACE OF BURIAL OR REMOVAL II Littlelow Mark
DATE OF BURIAL
Lec 4
13
190.
UNDERTAKER
ADDRESS
33 Prescott S fi Name of cemetery,
160
COMMONWEALTH OF MASSACHUSETTS
16/
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
bringsford - 66
FULL NAME
C.
2.12 Q. Hille
Place of Death *
Somerville Hospital Somerville Mass
Date of Death ..
November 5, 1903
.Age ..
. years ...
.3
.....
-
.months
days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME +
Cross
HUSBAND'S NAME +
Halliam Ho.
BIRTHPLACE # Barnard, Maine
NAME OF
FATHER
John J. Gross
BIRTHPLACE
OF FATHER#
Unknown
MAIDEN NAME
OF MOTHER
Mary CA. Liagine
BIRTHPLACE
OF MOTHER #
Unknown
OCCUPATION Home
INFORMANT §
PLACE OF BURIAL OR REMOVAL I!
Barnard Maine
UNDERTAKER
ADDRESS Francis M. Wilson Somerville
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ... 100 ...... te. .. 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 : Uraemna
Contributory :
.( DURATION).
DAY8
(Signed).
Frank J. Newton M.D.
190 (Address) /47 Highland ave Som Mass SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
Chelmsford, Mas
How long at
.Place of Death ?
.Days
Where was disease contracted,
If not at place of death ?.
Filed
Nov. 6, 1903, Levige & Vincent.
City 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
1
. (OURATION).
4
DAYS
DATE OF BURIAL
190.
.. Registered No ...
-0,5
1
K
١٠٠١
162
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Frau Mary Ellen
Doucette
Registered No.
67
/
Place of Death *
North Chelmsford
Date of Death.
December 8th
1903
Age.
3
. years
.months
250
.days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE # North Chelmsford:
NAME OF FATHER John Doucette
BIRTHPLACE OF FATHER# Nova Scotia
MAIDEN NAME OF MOTHER Fanny Hilson Convul,
BIRTHPLACE
OF MOTHER #
England.
OCCUPATION
INFORMANT §
John Doucette
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
iliness, from.
Lee 8
1903 to Lec.8? 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 :
Capillary Bronchitis
Two days
...... (OURATION) ..
DAYS
Contributory :
.. (DURATION). 0AY8
(Signed)
F &varney
M.D.
Dee 8
1903 (Address) March Chelmsford
SPECIAL INFORMATION only for Hospitais, Institutions, Transients, or Recent Residents.
Former or Usuai Residence
How long at Place of Death ?. .Days
Where was disease contracted, if not at place of death ?.
Filed Neuro
.1908
own Clerk
PLACE OF BURIAL OR REMOVAL !!
Edson Cemetery
...
DATE OF BURIAL
Dec.10
190.3
UNDERTAKER
Joseph albert
ADDRESS
vy Cheever
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, glve 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 statisticai details. || Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
Rec
فمالك
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
163
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Place of Death *
Chehneford
Date of Death.
Die Zott 1903
Age ..
68
years ..
.months
2
.days
STATISTICAL DETAILS
SEX COLOR Jemal White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
,
MAIDEN NAME + Emma Stockden
HUSBAND'S NAME + peter frich
BIRTHPLACE #
NAME OF FATHER Mothi
BIRTHPLACE OF FATHER#
MAIDEN NAME OF MOTHER
BIRTHPLACE
OF MOTHER #
OCCUPATION Athome
INFORMANT §
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from. 1903 to Dec 20 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 :
Cancer of Pancras
. (DURATION) ..
DAYS
Contributory :
Organic dienas 1 heard,
.. (DURATION) .. .. DAYS
(Signed)
JE Varney
M.D.
Dee 21 1903 (Address).
n. Chilunford,
SPECIAL INFORMATION only for Hospitais, 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 ?. 7
Flled Vec 22 1903 (120 , Je Tauhurst) (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 detalis.
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
do Chelmsford Die 22
190.3 :
UNDERTAKER
Act Memberdo
ADDRESS
lesA Name of cemetery.
Registered No.
68
:
COMMONWEALTH OF MASSACHUSETTS
164
RETURN OF A DEATH Clara BB Nmch ®
69
Registered No.
(
Place of Death *
Next
Date of Death
25.26
48
years ..
2
months
V
days
STATISTICAL DETAILS
COLOR
SEX Jemado phite
SINGLE, MARRIED, WIDOWED, OR DIVORCEDMarried
MAIDEN NAME + Clara B Butterfield
HUSBAND'S NAME Marcus H Kimchik
BIRTHPLACE #
NAME OF FATHER
BIRTHPLACE OF FATHER#
MAIDEN NAME OF MOTHER Philena, D. Füller
BIRTHPLACE OF MOTHER#
OCCUPATION
INFORMANT §
1 Marcus Ht Machine
PLACE OF BURIAL OR REMOVAL !! DATE OF BURIAL Michelmappa Dec 28 8
UNDERTAKER Les Membredo
ADDRESS Lawell
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that i attended deceased during last iliness, from. September 1902 to Dec. 252 903 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 : Sarcoma
One year one hand.
1. (DURATION).
DAYS
Contributory :
.(DURATION). DAYS
(Signed).
M.D.
Dee 250
... 190 ...... (Address).
SPECIAL INFORMATION only for Hospitals, institutions, Transients, or Recent Residents.
Former or
Usual Residence
Place of Death ?.
....
.Days
Where was disease contracted, If not at place of death ?
Filed Dec 28 1903
Cowon Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, glve 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. || Name of cemetery.
Rec
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
FULL NAME
Age
How long at
/65
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Sarah Bunker Reek
Registered No.
10
Place of Death *
Chelmsford
Date of Death.
the 28 1903
Age ..
77
years ...
.months
9
days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME Ť Mitchell
HUSBAND'S NAME +
Nathan adams Reef
BIRTHPLACE±
Swans Faland Me.
NAME OF FATHER Robert Mitchell
BIRTHPLACE
OF FATHER±
Either Scotland of Ireland.
MAIDEN NAME
OF MOTHER
Indith Staples
BIRTHPLACE
OF MOTHER #
Swan Island Me.
OCCUPATION Haservite
INFORMANT §
Mrs Ses a Kelley Chequeford.
Daughter
PLACE OF BURIAL OR REMOVAL II Edwin Com, Lowell
DATE OF BURIAL
Dze 30
1903
UNDERTAKER Walter Perham
ADDRESS
Chelmsford
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last iliness, from. V/100. 2 3 1903 to Lec 28, 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 : Myocarditis
.. (DURATION).
DAY8
Contributory : ..
Arteriosclerosis
Indefinite (DURATION).
.. DAYS
(Signed) ..
Arthur & Serbia.
.M.D.
Dec 30 1903 (Address).
Chehus fond mars.
SPECIAL INFORMATION only for Hospitais, 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
Dec 30 1903
Yo, A. Parliament
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
rec.
1
=
rATed
-
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