USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1904-1905 > Part 5
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21.3
RETURN OF A DEATH
City " O per
COMMONWEALTH OF MASSACHUSETTS
DATE OF BURIAL
Oct. 16
19011
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME Henry Herbert Cameron
.. Registered No.
4%
Place of Death *
Date of Death
Och 22/- 1904
Age
6.2
years.
a
months
6
days
/
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
NAME OF FATHER
BIRTHPLACE OF FATHER
MAIDEN NAME OF MOTHER aniva Dettifield
BIRTHPLACE OF MOTHER #
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL H poref actives tecpictures
DATE OF BURIAL Ved. 25
190.4
ADDRESS
UNDERTAKER Walter Dirham Chetime
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from ... Oct. 16 1904 to Oct. 22 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 : Fatty defineration of
the heart.
.. (DURATION). DAYS
Contributory :
/ .... (DURATION). DAYS
(Signed).
Amara Sto
toward.
M.D.
act.24 904 (Address).
Chelmsford.
SPECIAL INFORMATION only for Hospitals, Institutions, Translents, 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. 25
Edward J. Rafting
Com 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, glve 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.
214
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
1
1
215
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
CITY OF LOWELL
FULL NAME 1.2.1.4
Registered No. 48
Place of Death *
Date of Death,
00. Age 0
years
months days
STATISTICAL DETAIL
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME t
HUSBAND'S NAME +
-
BIRTHPLACE #
NAME OF FATHER
BIRTHPLACE OF FATHER #
MAIDEN NAME OF MOTHER
BIRTHPLACE OF MOTHER #
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL IT
DATE OF BURIAL
190.4 ...
UNDERTAKER
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY
that I attended deceased during last
illness, from Marcin .. 1904 to Oct. 221 .. 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 :.
Mipartie
one year
.(DURATION) .. . DAYS
Contributory :
vage Steinhagen never Mah 20-19;V ... . DAYS
JE. J'aieu M. D.
(Signed) ..
Oct. 24
.. 190 4 (Address) IS inten
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. 25 1904 Eduard . 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.
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.
ALL NAMES TO BE IN FULL
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
216
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH Hannah Boardman.
FULL NAME
Place of Death * Cast Chelmsford, Dass.
Date of Death.
Oct. 26 11904 Ade 56
years
months
days
STATISTICAL DETAIL
.
SEX trwale white COLOR
SINGLE MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Irland
NAME OF FATHER
BIRTHPLACE OF FATHER # ..
MAIDEN NAME OF. MOTHER ..
BIRTHPLACE OF MOTHER #
OCCUPATION
Of how
INFORMANT § Chaud. Boardman
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from .. . .
ffel
190 %. to.
Dens 100LL
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 :.
apoplusy
Eight months
.. (DURATION): DAYS
Contributory :
Loss of function
Following. appley (DURATION) .... DAYS
(Signed) ..
.. M. D.
Oct2 7 ,90 4 (Address) "Runels Bild'"
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. 28 .1904 Edward Nothing
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.
UNDERTAKER Lebr &Savage 169 Worther Name of f cemetery.
PLACE OF BURIAL OR REMOVAL !! Patrick Quetry
DATE OF BURIAL
4
ADDRESS
CITY OF LOWELL
Registered No.
49
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
C
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
FULL NAME Misael Lambert
Place of Death *
West Chelmsford Mass.
Date of Death.
Oct 28-
ock
Age.
: 78
years
7 months
25
.days
STATISTICAL DETAIL
SEX male
COLOR ,
White
SINGLE, MARRIED, WIDOWED, OR "DIVORCED"
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE ±
Canada
NAME OF FATHER Unknown
BIRTHPLACE OF FATHER # Canada
MAIDEN NAME OF MOTHER Unknown
BIRTHPLACE OF MOTHER # Canada.
OCCUPATION
at Home
INFORMANT § Edmond Lambert
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL If Joseph Cemetery Oef30 190. 5
UNDERTAKER Jouph albert
ADDRESS
(5) Cheever
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from:
Jawy
100% to Del.28
... 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:
Nephritis
Primary :
Two years
(DURATION) .. DAYS
Contributory : ..
(DURATION) .. DAYS JE Varney
. M. D.
(Signed).
2001.30
.. 190 .... (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 Oct. 30, 1904 Edward . Rolling 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.
217
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
CITY OF LOWELL
4
Registered No.
Varney -
..
---
1
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
COLOR
SEX Female White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Married
MAIDEN NAME +
HUSBAND'S NAME + Henry Election
BIRTHPLACE İ New Brunsich
NAME OF FATHER Charles A Haber
BIRTHPLACE
OF FATHER
/ 13
MAIDEN NAME OF MOTHER June Pendleton
BIRTHPLACE
OF MOTHER #
of 3
OCCUPATION
INFORMANT §
Charlesct Harfler
PLACE, OF BURIAL OR REMOVAL #
Lowell mars
DATE OF BURIAL
.1904
UNDERTAKER Das Menibeck
ADDRESS
so Imorales 4
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that Lottended Losoused during last
100
-
that to the best of my knowledge and belief death occurred on the
(late stated above, and that the CAUSE OF DEATH was of follows:
Primary :
Homicide
( Pestil the sound of brain
. (DURATION). . DAYS
Contributory :
(DURATION) ... . DAYS
(Signed).
7.11 Megs association Medical Exam
Nur. 1 1904 (Address) 160 Muninad h
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Lowall
How long at
Place of Death ?..
.. Days
Where was disease contracted, if not at place of death ?...
Filed Nov. 2 1901/ Edward J. Robbing
Join 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
218
FULL NAME
1
Entire
Registered No.
51
Place of Death *
Date of Death.
Clex 30Ht 1904
Age.
24
years
.months
days
STATISTICAL DETAIL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
UNDERTAKER
ADDRESS
RetMenibech su Midallely
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY ton Iattended deceased during fast
illness, from :190
... 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 :
Tuicide
(Pistol shot would flerain
.(DURATION). .DAYS
Contributory :
. (DURATION). . DAYS
(Signe
1 70 Meigs ausciate Medical Examhin
Nov 1 1904 (Address) 160 Marsnick h
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence ..
Domall
How long at
Place of Death ?..
.Days
Where was disease contracted, if not at place of death ?....
Filed Nov. 2 .... .1904 Guard ). Parking
Clerk
Com
* 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.
Il Name of cemetery.
CITY OF LOWELL
RETURN OF A DEATH
FULL NAME Henry & Eaton
Registered No.
52
Piace of Death *
Date of Death
Clex 30ft 1904
Age
30
years
months
days
STATISTICAL DETAIL
SEX Male Mahle COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED married
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Billerica mare
NAME OF
BIRTHPLACE OF FATHER # Newton Mark
MAIDEN NAME OF MOTHER
BIRTHPLACE OF MOTHER # Billeries man
OCCUPATION Sandnes
INFORMANT § Wilfredof Eatin
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL Billerica Mier den 3
190.54.
ul x 30- 219
COMMONWEALTH OF MASSACHUSETTS
220
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Stillborg, Bell
Registered No.
Place of Death *
Chelmsford
Date of Death.
1904.
Age
years.
.. months
days
STATISTICAL DETAILS
SEX
COLOR
white
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE #
Chelmotors
NAME OF
FATHER
arthur Bell
BIRTHPLACE
OF FATHER#
New Brunswick
MAIDEN NAME
OF MOTHER
Josie Jefrega
BIRTHPLACE
OF MOTHER #
Nova Scotia
-
OCCUPATION
-
INFORMANT §
Mro W. Jeffrey
PLACE OF BURIAL OR REMOVAL II Edom Con, Lowell
DATE OF BURIAL
nov 5
190.
UNDERTAKER Halten Puisham
ADDRESS
Chelmsford
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from.
11c. . ( 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 :
Unenature bath
1
(DURATION).
DAYS
Contributory :
........ (DURATION).
OAYS
(Signed)
"Writer Horton"
M.D.
Nov. 15 1904 (Address).
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
14 Eduard ). Rolling
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.
ALL NAMES TO BE IN FULL
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
1
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
22/
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
CITY OF LOWELL
FULL NAME afully Jagnon
Place of Death * north Chelmsford Mass.
Date of Death
Nov. 6Th Ord
Age
80
years
.. months
days
STATISTICAL DETAIL
Male While
SINGLE MARRIED, WIDOWED, OR DIVORCED -
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE #
Canada
NAME OF FATHER Louis Jagnon
BIRTHPLACE
OF FATHER #
Canada,
MAIDEN NAME OF MOTHER Emilie Deschère
BIRTHPLACE
OF MOTHER #
Canada.
OCCUPATION at Home
INFORMANT § Louis Gagnon, Dow.
PLACE OF BURIAL OR REMOVAL Il
DATE OF BURIAL
nov. 8
1905
UNDERTAKER Joseph albert
ADDRESS
5 y Cheever
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deggased during last illness, from. Non / 1903 to Wav 6 190 G 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 :..
Contributory :
(Signed).
DURachelto
M. D.
Non E 1904 (Address) 234 Merrimack
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 Nav-7
.. 190 .. 54 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.
V
(DURATION) ..
. DAYS
(DURATION).
. DAYS
Registered No.
54
Pochette
222
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
FULL' NAME
Patrick Moc Enancy
Registered No.
55
Place of Death *
North Glichnsford Ticas
Date of Death.
Nove 10
190 4
Age.
02
....
years
.months
days
STATISTICAL DETAIL
SEX
COLOR
w
SINGLE MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
Juelourd
NAME OF FATHER Patrick Me Erearly
BIRTHPLACE
OF FATHER #
Ireland
MAIDEN NAME
OF MOTHER
Aun ward
BIRTHPLACE
OF MOTHER #
OCCUPATION Will operative
INFORMANT §
Sylvester Me Eraney
PLACE OF BURIAL OR REMOVAL&
DATE OF BURIAL
St Patrickwall Nove 12
4
ADDRESS
UNDERTAKER
Las Halle Dennett 70 Gorman It
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from
nov. 6
190.4 to
Nov. 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 of follows:
Primary :.
Pneumonia
4
(DURATION) ...
.DAYS
Contributory :
.. (DURATION) .. DAYS
(Signed) ....
Umasa
Howard
... M. D.
Nav. 10 1904 (Address).
Chelmsford.
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
NOV /1 190%.
Edward . Potoma
Vonni 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.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
223
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
George Dennryder Registered No.
56
Place of Death *
Rebelsford Mareachucutts
Date of Death ..
You. 17. 19/04
Age 6%
years.
1
.months
.days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Halifax, It. S.
NAME OF FATHER George The Tryder erval 1
BIRTHPLACE OF FATHER# Halifax n.S.
MAIDEN NÁME OF MOTHER Parquet Hinter
BIRTHPLACE OF MOTHER #
OCCUPATION retired
INFORMANT § Mas. Gov. 1. Lyder ? 11
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from .. nor. 15, 190 11 to her.17+ 19011 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 :
Luft hemiplegia
(DURATION) ..
DAYS
Contributory :
('interio sclerose:
(DURATION). DAYS
(Signed) ..
-
M.D.
4201: 18 1904 (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 Nev. 18 1904 Edward Y Sitting
Clerk
PLACE OF BURIAL OR REMOVAL Il Window D. f.
nov. 20 190. 4
ADDRESS
UNDERTAKER 1 Halter Juham (Chelmsford.
DATE OF BURIAL LOV CUL * 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
.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME //h2
elvix
Stuart
Registered No.
5%
Place of Death *
Cchelieferch
Date of Death.
2200. 21-1964
Age.
23
. years ..
.months
19
.days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE # Inter. mme.
NAME OF
FATHER
Samuel Streack
BIRTHPLACE
OF FATHER#
Porter , me .
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER #
Porta, De
OCCUPATION Retired,
INFORMANT § Mro John & Stuart
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. 7100.€ 1904, to Nov. 2/1904 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 :
Chronic Bronchitis.
Several
years duration.
.. (DURATION).
Contributory : Old age
( DURATION
73 400.
(Signed).
Camada toward M.D.
NOV. 22 1904 (Address).
Chelmsford
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents., 1.5
Former or Usual Residence Place of Death ?. .Days
How long at
Where was disease contracted, if not at place of death ?
Filed 100 22
Edward ). Robbing
/
Town Clerk
PLACE, OF BURIAL OR REMOVAL II Edder, Teemeting Lowell maret
DATE OF BURIAL
LiEv. 2.3. 19041
UNDERTAKER
ADDRESS
D'aller Lesbian le feline fund.
* 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. | Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
221%
.225
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME Fiske
Luna Parkluat
.. Registered No.
58
Place of Death *...
Date of Death. Dr. 23-
01904
:Age.
.years ..
.months
.days
STATISTICAL DETAILS
SEX
m
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
NAME OF FATHER Edgar f. Park beef
BIRTHPLACE OF FATHER+
MAIDEN NAME OF MOTHER Edith May Breca
BIRTHPLACE OF MOTHER # Lowell, mais.
OCCUPATION
INFORMANT §
.
PLACE OF BURIAL OR REMOVAL il
DATE OF BURIAL
190.22
UNDERTAKER Walter Dechuans
ADDRESS
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from his 21, 1909 to for 23 90 !! 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 : (Atelectasia
. (DURATION) 2 DAYS
Contributory :
Canvis
.2 ..... (DURATION) .. DAYS
(Signed)\/
M.D.
Nov -23 1904 (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 Chov, 24 1904 Edward S. Rabbin,
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. || Name of cemetery.
ALL NAMES TO BE IN FULL
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
2
....... ....
226
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
CITY OF LOWELL
59
Registered No.
Place of Death *
Date of Death Nov 28, 1404
Age ....
.. years
months
days
STATISTICAL DETAIL
SEX
COLOR
SINGLE, MARRIED, WIDOWED OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE Į Gauchedige Muss.
NAME OF FATHER
7205 /12
BIRTHPLACE OF FATHER #
c . /
MAIDEN NAME OF MOTHER
1
BIRTHPLACE
OF MOTHER #
brefand
OCCUPATION
1 Gaudian
INFORMANT § Ano Mary a kedy
PLACE OF BURIAL OR REMOVAL/W
DATE OF BURIAL
UNDERTAKER
ADDRESS
324
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from .. .. 190.x5 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
1C:
M. D.
(Signed).
non. 29
.... 190 % .. (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 ?....
Flled Nov.30 1904 Edward Rollins
Com
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. Il Name of cemetery.
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
FULL NAME
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
226
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
CITY OF LOWELL
Registered No. 59
Place of Death * 120024, Chilius And Dass.
Date of Death Nov 28, 1404
.Age ...
N
years
months
days
STATISTICAL DETAIL
SEX
COLOR
Vibitte
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE Į bauchredige Muss.
NAME OF FATHER
BIRTHPLACE
OF FATHER #
V
c . /
MAIDEN NAME OF MOTHER
-
A
BIRTHPLACE
OF MOTHER #
detrol
Saudiar
INFORMANT § Aww Mary aKedy
PLACE OF BURIAL OR REMOVAL
DATEOF BURIAL 5
2 190 4
UNDERTAKER
ADDRESS
324
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ..
to "L: 29
... 190 %
that to the best of my knowledge and belief deatlı occurred on the
date stated above, and that the CAUSE OF DEATH was of follows:
Primary
..
Contributory :
.(DURATION). .. DAYS
18:
(Signed).
non. 2ª
.. 190 X .. (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 Nov.30 1904 Edward Raffina
Com
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.
(DURATION). DAYS
M. D.
OCCUPATION
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
FULL NAME
٠٠
2
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
MaryMaria Nurteen
60
Registered No.
Place of Death *
Chelunsford
(South Chelunsford)
Date of Death ..
one-IN 1 904
.Age ..
74
-
. years
.months.
.days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Married
MAIDEN NAME 1
Mary M Spalding
HUSBAND'S NAME t
Lorenzo Sweetser
BIRTHPLACE # Chelmsford
NAME OF
FATHER
Bengj Spalding
BIRTHPLACE
OF FATHER#
Chelmsford
MAIDEN NAME
OF MOTHER
Polly7: Prescott
BIRTHPLACE
OF MOTHER #
Westford
OCCUPATION
Housewife.
INFORMANT § Sarah Spalding
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