USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1906-1907 > Part 10
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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 detalis. Il Name of cemetery.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
STATISTICAL DÉTAILS
SEX COLOR female that
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
Tope
Sallay
HUSBAND'S NAME
alle m. Saury
BIRTHPLACE #
Unland
NAME OF FATHER not bunun
BIRTHPLACE
OF FATHER#
Guland
MAIDEN NAME OF MOTHER
.
BIRTHPLACE OF MOTHER # uland
OCCUPATION at Home
INFORMANT §
Sarah, MC Garry
Daughter un
PLACE OF BURIAL OR REMOVAL I It ilmy country Tourer
DATE OF BURIAL May 14. ... 190.
UNDERTAKER
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. May 1907 to Mayor .190.7% 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 :
.(DURATION). .. DAYS
Contributory :
(Signed)
YE Vaney
.(DURATION) .. ... DAYS
M.D.
may /3 190 (Address).
H. Chelundert
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
years ..
months .. days
Where was disease contracted, if not at place of death ?.
Filed may 14, 1907 Edward Rolling
Varm Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Informatinn." 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.
Il Name of cemetery.
18.5
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH Jose m Savory
(CITY OR TOWN.)
FULL NAME
Death * S
Place of ) Trenety Of North Chelmsford
Date of l
may /2 190)
Death
Residence
4
·
-
/ fr
Age
.years ...
.. months.
.days
Registered No.
.38-
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Sarah. R Lynch
Place of )
Death * S
123 Whitman I-
Death
Residence
H. Chelmsford
.Age.
21
.. years.
.months
days
STATISTICAL DETAILS
SEX
Female While
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME t Mollay
HUSBAND'S NAME t Patrick X Much
BIRTHPLACE #
4 nele Mans
Ance
NAME OF
FATHER
John J THollay
BIRTHPLACE
OF FATHER#
MAIDEN NAME OF MOTHER Martha A Afulda huldo
BIRTHPLACE OF MOTHER # Amhurst Man
OCCUPATION at home
INFORMANT § Husband
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL If Paliek Canceling Mary. 8 107
UNDERTAKER
C. H. Malloy.
ADDRESS
343Market Name of cemetery.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that i attended deceased during last iliness, from. Pet 9 1907 to ) May 16 .1907. 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 Inberculosis
our y can (DURATION). .. DAYS
Contributory :
.. (DURATION). ... DAYS
(Signed)
Saucif Ul. Qstrany
M.D.
May 17 1907 (Address) 16 Jahreer Sf-
SPECIAL INFORMATION only for Hospitais, Institutions, Transients, or Recent Residents.
How long at
Piace of Death ?
years ..
months. days
Where was disease contracted,
if not at place of death ?.
Filed May 17 190%, Edward J. Nothing
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,
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
186
39
Registered No.
Date of l
May 16
.1907
مسـ
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Joseph Servais
.Registered No.
40
Place of North, Shelunsford Maso
Death *
Date of l
May 18
.. 190
Death S
Residence
North Chelmsford Mass Age
.years.
.months ..
.days
STATISTICAL DETAILS
SEX Male
COLOR/
While
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
North Chelmsford Mass
NAME OF FATHER alexandre Servais
BIRTHPLACE OF FATHER# Canada
MAIDEN NAME OF MOTHER Rosie Barlow.
BIRTHPLACE
OF MOTHER #
Canada
OCCUPATION
Cti. Home
INFORMANT § Alexandre Gervais
PLACE OF BURIAL OR REMOVAL !! It Joseph's
DATE OF BURIAL
May 18
.. 190 7
UNDERTAKER Joseph albert.
ADDRESS
15% Sheever
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last iliness, from. May 18, 1907 to May 18, 1907, that to the best of foy knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary : Prematurity Juanition
Contributory :
.(DURATION) .. . DAY8
(Signed) ..
# 2. Varmes
M.D.
May /× 190% (Address).
No. Thelandlord
(SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
years ..
. months.
days
Where was disease contracted, If not at place of death ?
Filed May 18 1907 Edward . Bobbing
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 glving statistical details.
il Name of cemetery.
C
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
187
CITY OF LOWELL
.. (DURATION) ..
E
ء
COMMONWEALTH OF MASSACHUSETTS
Chelmsford. 188 CITY OF LOWELL
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME MargaretLivingston
.Registered No ...
41
Place of l
North Chelinktorch plass
Date of l
May 26
.....
190 7
Residence
. Age ..
.. years ..
.. months.
.days
STATISTICAL DETAILS
SEX
Lemale
·COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME |
I HEREBY CERTIFY that I attended deceased during last
illness, from.
May 26, 1907 to May 26, 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 :
Stillborn
... (DURATION). DAY8
Contributory :
.(DURATION) ..
. DAY8
(Signed).
(+ S. Varney, J.M.D.
May 27 90
... 190 ..... (Address).
no. Theline ord
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Piace of Death ? years.
months. days
Where was disease contracted, If not at place of death ?.
Filed May 27 1907 durand Robbing 60
Down 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 details, il Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
BIRTHPLACE # North theluns ford Mais.
NAME OF
FATHER
Andrew. A .Dumasto
BIRTHPLACE OF FATHER#
Alanda
MAIDEN NAME OF MOTHER Bridget Milelustry
BIRTHPLACE
OF MOTHER #
Ireland
OCCUPATION
INFORMANT §
Andrew J. Lecungslow Fighter
PLACE OF BURIAL OR REMOVAL I St Patricks Century
DATE OF BURIAL May 27 1907
UNDERTAKER
ADDRESS
PHYSICIAN'S CERTIFICATE -
Death * S
Death
5
C
1
COMMONWEALTH OF MASSACHUSETTS
189
CITY OF LOWELL
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Place of l
East Chelusterall
Date of ?
Klar 26
.1907
Residence
Age.
.years.
600
.. months ...
16
.. days
STATISTICAL DETAILS
SEX Finale
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE # East Chelmsford
NAME OF
FATHER
Tufis Gifford
BIRTHPLACE OF FATHER$
Laukmonth Mars
MAIDEN NAME OF MOTHER sie Chaffee
BIRTHPLACE OF MOTHER# arelance
OCCUPATION
INFORMANT § Mother
PLACE OF BURIAL OR REMOVAL II
Edson Cemetery
DATE OF BURIAL Kay 28 ,907
ADDRESS
# State or country ; also city, town or county, If known.
§ Name and address of person giving statistical detalls.
$4 & Market +Name of cemetery,
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, fro May 22 1907 May ZZ 1907 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 : Вганско-житогий
(DURATION) .. 6 DAYS
Contributory :
7
.(DURATIEN) ..
.DAYS
(Signedi)
M.D.
3/27 1907 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Place of Death ? .. . years.
. months days
Where was disease contracted, If not at place of death ?.
Filed May 28 100% Edward . Rolling
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.
UNDERTAKER C. H. Ifullay.
Milford
Registered No.
42
Death * S
Death
5
-
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
1
-
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
COMMONWEALTH OF MASSACHUSETTS
CITY 190 OF LOWELL
RETURN OF A DEATH
FULL NAME
alonzo Geld
Registered No ..
43
Place of Death *
East Chelmsford, maso
Date of Death
May 30, 1907
Age ..
CU years.
months
_days
STATISTICAL DETAIL
SEX
Male
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME Ť
HUSBAND'S NAME t
N. B.
NAME OF FATHER
Richard Feed
BIRTHPLACE OF FATHER $ France
MAIDEN NAME OF MOTHER Sarah Rockwell
BIRTHPLACE OF MOTHER #
N.B.
Jacksontown THE
OCCUPATION
Teamster
INFORMANT § Mrs. alongo Ged
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
St Patricks tem June1, 10%
UNDERTAKER
ADDRESS
I. a. Weinbeck so Middr. It
PHYSICIAN'S CERTIFICATE
I HEREBY
CERTIFY that I attended deceased during last
illness, from.
May 20 1907 to May 30, 1907
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 :
Heart Failure
Contributory
(Signed)
Solun Basket,
.. M. D.
May 31 1907 (Address) Lowall mans
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
May 31 1907 Edward. Rot
..
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 cemetry.
MARGIN RESERVED FOR BINDING ALL NAMES TO BE 'IN FULL.
BIRTHPLACE # Jacksontown, The.
. (DURATION) .. . DAYS
(DURATION). . . DAYS
How long at
COMEFr
191
COMMONWEALTH OF MASSACHUSETTS
ARLINGTON
RETURN OF A DEATH
NAME OF TOWN.
FULL NAME
Jesse Hartwell Johnson
44
Registered No.
Place of Death *
15Om Hillside One, arlington Heights, Trass.
Date of Death
May 18th, 1984
Age
70
.. years ..
6
months
1.4
days
STATISTICAL DETAILS
SEX Male Volite COLOR
WIDOWED, OR DIVORCED * Vidover
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE #
Cleveland Olio
NAME OF FATHER George 2 Dolimone
BIRTHPLACE OF FATHER# nalaut Mass
MAIDEN NAME OF MOTHER Betsy Lydstru
BIRTHPLACE OF MOTHER # Portsmouth, Ze .
OCCUPATION Betired stine cutter
INFORMANT § Sarah 2. Johnson
103 Stedman SF, Brookline
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that i attended deceased during last illness, from. May 10 1907 to Way 18 /907 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 :
Fabular disease of the
Mart
eral minettes standing
RATION ).
DAY8
0 of ser-
Contributory :
nephritis
cannot sou ... (DURATION) DAYS
(Signed).
allan Mot quia
M.D.
May 18- 1907 (Address). 1
Arlington Heights
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
E. Chelmsford. huas
dce of Death ?..
.. Days
Where was disease contracted, If not at place of death ?.
Filed may 21- 190.
homas / lotmenu
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
PLACE OF BURIAL OR REMOVAL II Yowell Mass
UNDERTAKER
ADDRESS
A. H. Hartwell Tion arlington
DATE OF BURIAL Tway 21 190 7
COMMONWEALTH OF MASSACHUSETTS
192
RETURN OF A DEATH
FULL NAME:
Place of Death *
1
Date of Death.
.Age
years
-. 3 .. months days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME
HUSBAND'S NAME t
BIRTHPLACE #
NAME OF FATHER
0 Raffina 1
BIRTHPLACE OF FATHER
MAIDEN NAME OF MOTHER
Milk Shani England Emmaliand Parks
BIRTHPLACE OF MOTHER # Brad ford England
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL Ho Halmstad Surnell 1907
UNDERTAKER I'D rotten
ADDRESS Na. Chelnefit
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from. June 16, 190% to uuml 10,90%. 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 :
. (DURATION). DAY8
Contributory :
(DURATION). DAYS
(Signed)
.M.D.
Jeme10, 1907 (Address). Yo. Cellelive food
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 June 11 1907 Eduard , Robbins
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
Robbing
Registered No.
45
Jun
=
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
CITY 193 OF LOWELL
FULL NAME Fraunce L, Page
Registered No ...
46
Place of Death *
Centre St, East Chelmsford!
Date of Death
June 10, 1909
Age ..
7
. years.
/. months
11 days
,
STATISTICAL DETAIL
SEX Male
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME $
BIRTHPLACE # West actor, Maso
NAME OF FATHER Larry L. Page
BIRTHPLACE OF FATHER ₲
Burlington, Maine
MAIDEN NAME OF MOTHER Elizabeth Go man
BIRTHPLACE OF MOTHER St. John n. B.
OCCUPATION
INFORMANT § Harry, L. Page
PLACE OF BURIAL OR REMOVAL !! Edson Cemetery
DATE OF BURIAL Gruene 12, 1907.
ADDRESS -
UNDERTAKER I.a. Weinbeck, so Meddy, St.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ..
Jum 80, 1907 to Gener0 1907
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) Sex ... DAYS
Contributory
.(DURATION). ... DAYS
(Signed)
Wesley Sawyer M. D.
Gull 1907 (Address) 222021
neon fr
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 June 12 190 7 Edward . Robbing
... Vous Clerk.
*City or Town, street and number, if any. If death occurs away from USUAL RESIDENCE, give facts called for under " Special Information.' Hospital or Institution, give its NAME instead of street and number.
If in a
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 cemetry.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL.
1
HEJnSW OF Y DEVAW
TOMEST 90
017000284.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
STATISTICAL DETAILS
SEX Male
COLOR
what
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE #
NAME OF FATHER William
BIRTHPLACE OF FATHER France
MAIDEN NAME
OF MOTHER
Unknown
BIRTHPLACE
OF MOTHER #
11
OCCUPATION
Low Cutler
INFORMANT § Trank Mallerin
PLACE OF BURIAL OR REMOVAL !!
DATE, OF BURIAL tra 201 190 7
UNDERTAKER
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Lucy 1 1907 to que 21 1907, 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 : Heat- Balance
. (DURATION).
.. DAYS
Contributory :
Cancer of House
.. (DURATION). ... DAYS
(Signed)
& a Parlare M.D.
que 22 90) (Address).
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
.. years ..
months.
days
Where was disease contracted,
If not at place of death ?.
Filed June 22 1907 Edward J. Robbing
Jorn
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. Il Name of cemetery.
194
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
William Do Maison RETURN OF/A/ DEATH
(CITY OR TOWN.)
FULL NAME
Place of annetable Road, North Chaluneford
Date of l
Death *
.......... 190
Residence
2
Age ..
63
.. months.
.. days
47
.. Registered No.
=
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
195 Chelmsford
(CITY OF TOWN.) 118
FULL NAME
Vinter richardson Macnutt Registered No.
Place of Thelensford, Mars.
Date of )
june 26
.1907.
Residence
-
Age.
67
.. years ..
months .. 9 .days
STATISTICAL DETAILS
SEX
M.
COLOR~
W.
SINGLE, MARRIED, WIDOWED, OR DIVORCED PR Married
MAIDEN NAME + HUSBAND'S NAME t
BIRTHPLACE # Debeck Colchester les. n.f.
NAME OF
FATHER
John Brown Wacmult.
BIRTHPLACE OF FATHER# "Maschon, h. S
MAIDEN NAME OF MOTHER Mary Eachman
BIRTHPLACE
OF MOTHER+
Masslowon, n. S.
OCCUPATION Farmer
INFORMANT §
tuch Machutt
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL West leem Chelmeto June 28 197
ADDRESS
UNDERTAKER
Waller Veckan lehe hunston
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from May 4, 1907 to Jene 26 190%, that to the best of my knowledge and bellef death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary : Myocarditis
. (DURATION). DAYS
Contributory :
.... (DURATION).
DAY8
(Signed) ..
Fage
M.D.
June 27, 190% (Address) Ho. Delunsford.
SPECIAL INFORMATION only for Hospitais, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
.. years.
months. days
Where was disease contracted, If not at place of death ?
Filed Jeme 2st 1907 (dmand. Roffi
Vom 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 details. li Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
Death * S
Death
COMMONWEALTH OF MASSACHUSETTS
196
RETURN OF A BI
(CITY OR TOWN.)
FULL NAME Lake Louise Pancol
Registered No. 49
June 29
.. 190
9
.months.
22
....
.days
STATISTICAL DETAILS
SEX
COLOR
while
SINGLE, MARRIED, WIDOWED, OR DIVORCED Single 0
MAIDEN NAME t
HUSBAND'S NAME +
BIRTHPLACE# Lowell Mas.
NAME OF FATHER
Nabokan
BIRTHPLACE OF FATHER#
MAIDEN NAME OF MOTHER Mary Gry
BIRTHPLACE OF MOTHER# Lowell Mass.
OCCUPATION
INFORMANT § Napohan fanctal
2/ 1
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
.. 190.
UNDERTAKER Fat Lavage 169 Wortlaut
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from flere 24th 1907 to June 28- 907, 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 :
Leo Calitio
.
Contributory :
(Signed)
Thauvin
... (DURATION).
.. DAYS
M.D.
/1907 (Address).
546)44&Ev.
SPECIAL INFORMATION only for Hospitals, Institutions, Translents, or Recent Residents.
How long at
Place of Death ?
.. years.
months. days
Where was disease contracted,
If not at place of death ?.
Filed Aimer 29 1907 (amand ating
Clerk
Vom
* 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
Death * S
Place of ) Golden Cour Chelmsford
Date of }
Death
Residence
Golden
Age
.years.
CITY OF LOWELL
(DURATION).
8
.. DAYS
COMMONWEALTH OF MASSACHUSETTS
197
Chelmsford
(CITY Of TOWN.) 50
FULL NAME
horison
Place of l
Thelistord
Death * S
Residence
Chelicheford
Age.
84
.. years.
3
months.
12
.days
STATISTICAL DETAILS
SEX Hemale
COLOR
white
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED Medow
MAIDEN NAME +
Elizabeth Thompson
HUSBAND'S NAME t Robert Meyer
BIRTHPLACE # Paisley, Scotland
NAME OF FATHER John Thomson
BIRTHPLACE OF FATHERI Paisley Scotland
MAIDEN NAME OF MOTHER Christina Mether
BIRTHPLACE OF MOTHER # Paisley Scotland
OCCUPATION
athome
INFORMANT § Mrs James ashworth
PLACE OF BURIAL OR REMOVAL II
Horefattero Cem.
DATE OF BURIAL
July 3
.190 .. 7.
UNDERTAKER ADDRESS Walter Perkam Chelmsford
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ..
1907 to July 1, 1907.
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 :
Sembiti
(DURATION).
DAYS
Contributory : ..
(Signed).
Auchun Y Scobixa M.D.
190(Address).
SPECIAL INFORMATION only for Hospitals, institutions, Transients, or Recent Residents.
How long at
Place of Death 7
.years.
months. . days
Where was disease contracted,
If not at place of death ?
Filed July 3
0% Edward & Robbing
Down
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. || Name of cemetery.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
RETURN OF A DEATH
Elizabeth Thomson Mcgee
Date of l
Registered No.
July 2
Death -
1907
...... (DURATION) .. DAYS
COMMONWEALTH OF MASSACHUSETTS
198
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Frank
Prescott
Place of 1
Chefqueford
Death *
5
Residence
Chelangford
Age.
.years.
5-1
.. months.
11
.. days
STATISTICAL DETAILS
SEX
1
Male
COLOR
white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME + HUSBAND'S NAME t
BIRTHPLACE +
Springfield
NAME OF FATHER thank R Prescott
BIRTHPLACE
OF FATHER#
Westford
MAIDEN NAME
OF MOTHER
annie DaLong
BIRTHPLACE OF MOTHER # Sheffield n. B.
OCCUPATION
INFORMANT § Father
PLACE OF BURIAL OR REMOVAL !
DATE OF BURIAL Fairview Cesar Westrd July 22,90>
UNDERTAKER
ADDRESS Chelmsford
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from. habe 2 1907 to.
that to the best of my knowledge and behef death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
about
.. (DURATION).
4.
.DAYS
Contributory :
DURATION) ...
DAY8
(Signed)
Annua S. Scobona M.D.
July 22 190] (Address) Chalana And Because
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
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