USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1904-1905 > Part 4
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BIRTHPLACE # England
NAME OF
FATHER
Joseph Hatfield
BIRTHPLACE
OF FATHER#
England
MAIDEN NAME
OF MOTHER
Mary Brooks
BIRTHPLACE
OF MOTHER #
England
OCCUPATION
at Home
INFORMANT § mrs. Jarvis Words
PLACE OF BURIAL OR REMOVAL II
Belleview Cemetery
Laurence Dass
DATE OF BURIAL
aug. 15 1904
UNDERTAKER
John Heinbeck
PRES alesex St. Powell mars
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Lug. 5 190 4 to Clung, 12 1904, 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 : Semile
(DURATION).
DAY8
Contributory :
(Signed)
Amara Howard
.. M.D.
aug. 12 1904 (Address).
Chiliand.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
Place of Death ?.
Days
How long at
Where was disease contracted, If not at place of death ?
Filed
Cinq. 12 1904
Quand J Getting
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.
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. Il Name of cemetery.
201
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
CITY OF LOWELL
.Registered No ..
34
(DURATION) .. DAYS
202
FORM C.
.
Commonwealth of Classachusetts.
No.
RETURN OF A DEATH. Registered No. 35 To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Lova May Hartiveis
Sex, Fernaux Color,
Date of Death,
august 11
190 4; Age, 41 Years, 3 Months,
8 Days.
Maiden Name,
or divorced.
Lora May
Bickford
Husband's Name, Tilla Do Martil
Single, Married, Widowed or Divorced, Married Occupation, At home
*Residence, { If out of town, }
¿ also state fully.
Gaston Mass.
Place of Birth, Hampton U. 2.
*Place of Death,
South Chelmsford Mass
Daniel It. Bickford At
Name and Birthplace of Father,. 1
Maiden Name and Birthplace of Mother, Agusta De Clough- Gilmanton 2. 26.
Place of Interment, (Give name of Cemetery),.
Dated at. So. Chelmsford
on
August 12,
1904.
Signature and place of business of Undertaker. So. Chelmsford./
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Lora M. Hartwall-
Age, 41 x3 M. 8 D.
Place and Date of Death,
died at
So Chelmsford, mars,
Cinq. 11,
Primary,
Malignant Disease
Duration,
Disease or Cause §
of Death, #
Secondary,
of Stomach-
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S
Antu J. Scolonia
M. D.
of Certifying l'hysician. Chiberesford, mais.
Date of Certificate,
Ling. 12
1904.
* 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 Secondary Cause.
Countersign and transmit to the clerk of the city or town.
......
Agent of Board of Health.
No.
RETURN OF THE DEATH
OF
at
Date,
190.
Filed,
190.
[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]
SECTION 6. Every householder in whose house a death oeeurs, 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 eity or town in which the death occurred.
SECTION 7. The commanding offieer 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 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 faets.
SECTION 11. In ease the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate eause of death as nearly as he ean state the same. Penalty for refusal or negleet, 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 withi seetion 10, and return it, together with the facts required by seetion 1, to the board of health or to the elerk of the eity 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 sueh 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 sueh statement and certificate are delivered to the Board of Health, the board or agent shall forthwith countersign and transmit the same to the elerk of the city or town for registration.
SECTION 5. Penalty for violation not exceeding fifty dollars.
203
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME Hamials Mº Im
ess Registered No.
36
Place of Death *
Sich an
Chelmsford
Date of Death.
august, 11, 1904 Age 70
years
_months
days
STATISTICAL DETAIL
SEXY Je
COLOR
wh
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME f
Hannah Ketter
HUSBAND'S NAME + William mc Guinness
BIRTHPLACE #
Ireland
NAME OF
FATHER
Daniel Kelley
BIRTHPLACE
OF FATHER #
Ireland
MAIDEN NAME OF MOTHER Hannah not known
BIRTHPLACE
OF MOTHER #0
Obrelands
OCCUPATION at Home
INFORMANT § Daughter
PLACE OF BURIAL OR REMOVAL | Pavel Patricks Cemetery ang 13, 2 ADDRESS
/ .. 190. 4
UNDERTAKER
Ott, molloy Lowall Mark.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ..
Seat 4
1903 to Cuy/2/2020
that to the best of my knowledge and belief death occurred on the
date stated above and that the CAUSE OF DEATH was of follows:
Primary :..
стережений
(DURATION). DAYS
Contributory :
.(DURATION). . DAYS
(Signed) ..
Last. Soudlucas
M. D.
audi DA (Adress) V40 Clearfor SK
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Former or
Usual Residence.
Place of Death ?.
. Days
Where was disease contracted, if not at place of death ?..
Filed mg. 12, 1904 Erard & Robbin Town Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESIDENCE, give facts called for under "Special Information." If in a Hospital or Institution, give its NAME instead of street and number.
+ 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.
CITY OF LOWELL
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
, DATE OF BURIAL
1
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
-
COMMONWEALTH OF MASSACHUSETTS
204
RETURN OF A DEATH
FULL NAME
Brown
Registered No ..
37
Place of Death *
Chelmsford mass.
Date of Death ..
Rua 18
1
1904
Age.
1 hour
.years .. .. months. .. ... s
STATISTICAL DETAILS
SEX
COLOR
20
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE #
Chelmsford, Mass
NAME OF
FATHER
Frank HO Brown
BIRTHPLACE
OF FATHER#
Lowell Mass.
Mass.
MAIDEN NAME OF MOTHER( Mabel a Rose
BIRTHPLACE OF MOTHER # Chelmsford, Mas
OCCUPATION
INFORMANT § Thank HOSBrown.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from.
1904 to
1904 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 :
Premative Berth
Daniel 1 hour
...... (DURATION) ..
DAYS
Contributory :
(Signed)
Active O Scoloria,
.. M.D.
Chry 18 1904 (Addres).
Chelmsford, Man.
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
6.1904 Canard & Rafting
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 detalls.
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
Forefathers Cen.
Chelmsford, masthug 18
1904.
ADDRESS
UNDERTAKER Walter Tenham Che
ochusfor" Name of cemetery.
( DURATION).
DAYS
كب
-
0.0
FULL NAME
Place of Death.
Date of Death
25- 1904 Age.
42 years
months. days
STATISTICAL DETAILS
SEX Mala
COLOR white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME Ť
HUSBAND'S NAME T
BIRTHPLACE West Subjec, MR.
NAME OF FATHER
BIRTHPLACE OF FATHER + (
Irland Mary Suche
MAIDEN NAME OF MOTHER
BIRTHPLACE OF MOTHER +
Enmeville
OCCUPATION Machinist
INFORMANT § Mary Haggerty
PLACE OF BURIAL OR REMOVAL Trescott file.
DATE OF BURIAL Und. 26. 190.4
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from aug. 23 190.56.to. Clug. 25 1904. 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
congration.
.. (Duration) Days
Contributory :
waar heart
(Duration) Days
(Signed;
Amara Howard
. D.
aug. 25 1902 (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 ?
Filed Chey. 26, 1904 Eduard J. Robbins Tom Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESIDENCE, 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.
Sehr A Savage 169 Wortheach #Stałe or country; also city, town or county if known: Name and address of person giving statistical details. mere Name of cemetery. Lowill e-c 8178
205
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH Gu Hagarry
Registered No.
38
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
L
C
C
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
Cometwofor Mas. CITY OF 206 LOWELL
RETURN OF A DEATH
FULL NAME Thomas S. Donahoe
Registered No.
39
Place of Death *
Bullivrea Sy Bulun for L Muss.
Date of Death
Aug 28. 1964
Age
de 50
years
months
days
STATISTICAL DETAIL
SEX
Mule
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME
HUSBAND'S NAME +
BIRTHPLACE #
Fornich Muss.
NAME OF
FATHER
Michael D. Donahue
BIRTHPLACE
OF FATHER #
YElland
MAIDEN NAME
OF MOTHER
Ellen Nagquity
BIRTHPLACE
OF MOTHER #
Pulauch
OCCUPATION Machiniste
INFORMANT §
Jelovens Donaha, Brother
PLACE OF BURIAL OR REMOVAL MI
DATE OF BURIAL
St Patricks Rowall Aug 31
ADDRESS
324
UNDERTAKER IF. Intermultisom market It
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ..
Aug.28 190 4 to
Cluq.28 1904.
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was of follows:
Primary :..
apoplexy
:
12 hours
.(DURATION).
... DAYS"
Contributory :
?. (DURATION).
. DAYS
(Signed) ...
Cimava Howard M. D.
Ing.29
. 190 4 (Address).
1
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence.
Place of Death ?..
. Days
How long at
Where was disease contracted,
if not at place of death ?..
Filed aug 29, 1904 Edward & Rabbins
Joun Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESIDENCE, 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
1
COMMONWEALTH OF MASSACHUSETTS
0207
RETURN OF A DEATH Chistes A Sunatle
Registered No.
40
Place of Death * h.
Date of Death.
1904
Age
years
4 .. .. months
22 days
STATISTICAL DETAILS
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
NAME OF FATHER Alferd Burthe
BIRTHPLACE OF FATHER# England
MAIDEN NAME OF MOTHER Gorgana Kenney
BIRTHPLACE OF MOTHER # Suncork & H
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR . REMOVALIL
DATE OF BURIAL
no Chelmsford
UNDERTAKER
ADDRESS No Chelmsford
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. 190 ..... 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 :
Enteritis. I had not seen
child but from description A seekers. Think it. the above
(DURATION ). .. DAYS the suspicion of four play Contributory :
.(DURATION).
. DAYS
(Signed)
Sell. 2
190 Y (Address)
FE Varney
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 Selit 3
4. Eduard S. Kobling
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.
|| Name of cemetery.
M.D.
FULL NAME
JT
1
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. THIS IS A PERMANENT RECORD
=
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Almira W. Symmes.
Registered No.
41
Place of Death *
South Chelmsford, Mass.
Date of Death ..
September 11, 1904.
Age 79
years ...
.months
8
days
STATISTICAL DETAILS
SEX
Female.
COLOR White.
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME+ Almira w. Wiley
HUSBAND'S NAME +
Henry Symmes.
BIRTHPLACE # Warren, maine
NAME OF
FATHER
Robert Willy
BIRTHPLACE
OF FATHER
Belfast, maine
MAIDEN NAME OF MOTHER Abby Wilson
BIRTHPLACE
OF MOTHER#
Belfast maine.
OCCUPATION
At home.
INFORMANT § Mrs. E. Andrews
PLACE OF BURIAL OR REMOVAL | Soll SO Onumpl ard
DATE OF BURIAL Sept. 13, 190 4.
UNDERTAKER 5 25 Ford 6em Danil. T. Byam
ADDRESS So. Chelmsford mass.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Jekat. 8 1909 to Sept. 10,1904. 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).
DAYS
Contributory :
Senility
(Signed)
Antun sy Scobona
.M.D.
Sept. 11, 190 (Address) Chebrusford, mais.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
Place of Death ?
Days
How long at
Where was disease contracted, if not at piace of death ?
Filed Seht 14 1904 Edward S. Robbins
atting
Joan 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 statisticai details. Il Name of cemetery.
ALL NAMES TO BE IN FULL
208
.Q ... (DURATION).
DAYS
209
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
FULL NAME
Jubel A. Stickney
42
Registered No.
...
Place of Death *
Date of Death
Seket 21281904 Ade 72
years
11
.months
28
days
STATISTICAL DETAIL
SEX Female Write COLOR
SINGLE, MARRIED? WIDOWED, OR DIVORCED
MAIDEN NAME +
Sybel It Hendem
'S NAME Samuel Stickend
BIRTHPLACE
NAME OF FATHER Seth Hendeon
BIRTHPLACE OF FATHER ¢ Authenown
MAIDEN NAME OF MOTHER Lydia Miller
BIRTHPLACE OF MOTHER #
OCCUPATION
INFORMANT § Det Hender No thelmenos
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL Dimmereton x Seler 294
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from
Jul. 2pst
-190 4
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was of follows:
Primary :
angina
1
Victoria
.ĐÂY9
Contributory :
(Signed).
FE l'amer
M. D.
Soll. 23
.. 190 4 (Address).
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence. Place of Death ?.. Days
How long at
Where was disease contracted, if not at place of death ?..
Filed Sept. 23, 14 Canard J. Roffi
Conn Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESIDENCE, give facts called for under " Special Information." If in a Hospital or Institution, give its NAME instead of street and number.
In case of married or divorced woman, or widow. # State or country ; also city, town or county, if known.
80 finalalleecome and address of person giving statistical details. || Name of cemetery.
bonellineves
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
UNDERTAKER LA Hembecke
ADDRESS
1
5 hours
(DURATION).
.(DURATION) . DAYS
1
210
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
FULL NAME
allary a
evokue
Registered No.
43
Place of Death *
.....
North chelausford Mass
Date of Death
Sept 23 1904
Age
years
10
months
days
STATISTICAL DETAIL
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # North & helensford Mass
NAME OF FATHER Jaunes R looking
BIRTHPLACE OF FATHER # Lowell
MAIDEN NAME OF MOTHER Catherine Dungen
BIRTHPLACE OF MOTHER # North Cheburford 1km
OCCUPATION
INFORMANT § James R Gookin
PLACE OF BURIAL OR REMOVAL II St Patrick
DATE OF BURIAL
Soft 25
4
ADDRESS
UNDERTAKER For the Dermott To gorkan st
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from .. Sept. 20 1904 to Sep. 23 190 %, that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was of follows: Primary :.
.(DURATION) DAYS
Contributory :
.(DURATION) .. DAYS
(Signed).
Quer Pinhão
.M. D.
Seft. 24 1904 (Address).
. .
253 Contra st 2mall
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
How long at
Place of Death ?.
Days
Where was disease contracted, if not at place of death ?...
..
Filed Sept. 24 190 4 Edward Rotting
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESIDENCE, give facts called for under " Special Information." If in a Hospital or Institution, give its NAME instead of street and number.
1 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.
ALL NAMES TO BE IN FULL
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
211
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A, DEATH
FULL NAME
Williamtidans Duceland
.Registered No.
44
Place of Death *
Chelmsford Mass.
Date of Death.
Sept. 28, 1904
Age.
65
0
years ...
... months
24
.days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # North Waterford, maine
NAME OF FATHER
leben
neeland
BIRTHPLACE OF FATHER*
(Bridgton maine
MAIDEN NAME
OF MOTHER
Hannah libbets
BIRTHPLACE
OF MOTHER#
Verment
OCCUPATION farmer
- INFORMANT §
Aire Kneelands
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Sikt. 1902 to Let. * 1904, 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 :, Malianauf Dercare
Of Recién
J'aiver Brits
(DURATION).
DAYS
Contributory :
(DURATION). DAYS
(Signed)
M.D.
Sept 20 190 (Address) 2
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 Selvt. 30 1904 Edward J. Potting
Clerk
Com
* 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.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVAL II forefathers leencating
DATE OF BURIAL
Sept 29 1904
UNDERTAKER
tratted Fecham
ADDRESS
Chelmsford) \ Name of cemetery,
212
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
FULL NAME
0
James
al Brown
Registered No.
45
Place of Death *
West Chelmsford maso
Date of Death
Oct 6. 1904
Age 59
years
4
6
months
days
STATISTICAL, DETAIL
SEX male
COLOR
white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE
Scotland
NAME OF FATHER Thomas & Brown
BIRTHPLACE
OF FATHER #
Scotland
MAIDEN NAME
OF MOTHER
Margret Dick
BIRTHPLACE OF MOTHER # Scotland
OCCUPATION
Retired
INFORMANT § Thomas Brown
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
Vest Chelmsford bet 8
. .. 190. . y
UNDERTAKER
ADDRESS
6. In. Young fr 33 Prescott 2,
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
Widowed illness, from .. .190 .... 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 of follows:
Primary
Pleuritis (Chronic).
(DURATION). DAYS
Contributory : Indefinite Cerebral yspinal cym (DORT] fre- ... (DURATION) ... .. DAYS
(Signed).
& acthiu Lage. M. D.
Oct 7 1904 (Address) 64 Culate 82
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence. Place of Death ?. . Days
How long at
Where was disease contracted, if not at place of death ?..
Filed Oct. 7.
190%.
Edward J. Rolfme
1
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESIDENCE, 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.
Ci
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
FULL NAME
Robert Venninnen.
Registered No.
1393
Laurell Hospital Lowell Mass
Place of Death *
Date of Death
C.et. 13. 1964
Age ..
67
years ..
3
months
.days
STATISTICAL DETAILS
SEX
m.
COLOR
IV
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE # -Windsor V.t
NAME OF
FATHER
BIRTHPLACE
OF FATHER
Linkuemne
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER #
Unknown
OCCUPATION
INFORMANT § Geo Termim
1.10. innenvan
PLACE OF BURIAL OR REMOVAL II
-
UNDERTAKER
6. M. Yomg + 60
ADDRESS
33 Prescott st
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last iliness, from. (11. 12 1904 to Cit. 13 1904 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 :
Strangulated Hernia
abril
(DURATION) ...
21
DAYS
Contributory :
(DURATION).
.. DAY 8
(Signed)
M.D.
Ort 15 904 (Address) Livwell Mars 41
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
Chilsford
1111
Place of Death ?
How long at
/
.Days
Where was disease contracted,
If not at place of death ?
Chelmsford,
Filed Oct. 1/ 1904 Girard Mailman
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. I Name of cemetery.
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