USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1906-1907 > Part 11
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How long at
Place of Death 7
years.
months. days
Where was disease contracted, If not at place of death ?
Filed Chilly 92 190 7 Edward Ksthing 0
Clerk
Pour
* 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 ALL NAMES TO BE IN FULL
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
Registered No.
51
Date of )
July 22
.1907
.... Death
?
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME .
Prenda Do. Huchina
Registered No.
Date of l
Death
July
20, 1907
<
.months ..
............... days
STATISTICAL DETAILS
SEX
COLOR
Female White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
Lunda Healey Woods
HUSBAND'S NAME }
Thomas S. Huckino
BIRTHPLACE # Francistown, I.E.
NAME OF FATHER issac Words
BIRTHPLACE OF FATHER# Francistown n.H.
MAIDEN NAME
OF MOTHER
Mary Healey
BIRTHPLACE
.OF MOTHER #
Washington, hab.
OCCUPATION
INFORMANT §
ving VI. Huckens
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
north Chelmsford July 23, .19
...
ADDRESS
UNDERTAKER a. Heinbeck st. Diddy- St
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ..
190 ...
... to
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 :
nephritis
. (DURATION). DAYS
Contributory :
Praemia
.. (DURATION). .. DAY8
(Signed).
M.D.
190 ...... (Address).
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 ?.
4
Filed
July 23
190% Edward J. Robbing
Vorm 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.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
Place of )
Chitadelphia. Pa
Death * S
Residence
Philadelphia (Pr)
Age
79
.. years.
198.1
CITY OF LOWELL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME Joseph Within Servais
Place of l
Chelmsford Centre
Death * S
Residence
Chelmsford Center
....... Age
.years.
10
months.
6
.days
STATISTICAL DETAILS
SEX
m.
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Chelmsford Brass
NAME OF FATHER adelard Gervais
BIRTHPLACE
OF FATHER#
Canada
MAIDEN NAME OF MOTHER
adeline Regard July 2 07 (Address) 46Madloest
.... 190 .. 7 ... (Address)
BIRTHPLACE
OF MOTHER #
Canada
OCCUPATION
INFORMANT § Father
PLACE OF BURIAL OR REMOVAL 11
St. Josepho"
DATE OF BURIAL July 23,90 7
ADDRESS
UNDERTAKER hab Bilodeaus X "May
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from.
July 1.2. 1907 to July 22 1909
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 :
Gastro Enteritio
.. (DURATION) 10
DAYS
Contributory :
.. (DURATION). .. DAYS
(Signed) ..
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents. 1
How long at
Place of Death ?
.years.
months. days
Where was disease contracted,
If not at place of death ?
Filed July 23 1907 Eduard . Robbing
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.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
.
Registered No.
52
Date of l
July 22
190
Death
5
199
CITY OF LOWELL
-
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
CITY 200 OF LOWELL 53
FULL NAME frances In Duncan
Registered No ..
Place of Death *
north Chelmsford maso
Date of Death
aug
.1987
Age.
82
years.
2
months
days
STATISTICAL, DETAIL
SEX
Female
COLOR white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
widow
MAIDEN NAME 1
Frances M. Taylor
HUSBAND'S NAME + nathaniel Diencan date stated above, and that the CAUSE OF DEATH was of follows :
BIRTHPLACE #
Barrgington n H.
NAME OF FATHER Asean Taylor
BIRTHPLACE OF FATHER Į
Beverly mass
MAIDEN NAME OF MOTHER
Pheobe Butterfield
BIRTHPLACE OF MOTHER # Francestor n. #
OCCUPATION
at
ne
INFORMANT §
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL Riverside Gemetry aug 3 107
ADDRESS
UNDERTAKER l'in. young to 33 Prescott sf
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
,
illness, from.
Inky 23 1907 to Tuq 1
. .
190 ... ,
that to the best of my knowledge and belief 'death occurred on the
Primary : ...
Organiz desear 1 horas-
ninth
.. (DURATION) .. DAYS
Contributory
.... (DURATION). ... DAYS
(Signed)
.M. D.
aug / 1907 (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 ang 3
190 7 Edward & Vatting
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 kuown.
§ Name and address of person giving statistical details.
I"Name of cemetry.
MARGIN RESERVED FOR , BINDING ALL NAMES TO BE IN FULL.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
DEVEM
FOMETP CALL 4
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended/ deceased during last illness, from. Cifre 13 1904 to July -23 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 : Cancer of Intestines
... (DURATION) ..
DAYS
Contributory : 6
(DURATION) 1
.. DAY 8
(Signed)
Horster R. Smith
M.D.
July 24190y (Address) Lowell Mars
SPECIAL INFORMATION only for Hospitais, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
years ..
3
.. months.
days
Where was disease contracted, if not at place of death ?
Filed July 26 1904
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.
54
FULL NAME
Place of ?
City Markt
Date of l
Death * S
Residence
no Chelmsford
Age
6,
.. years.
.. months.
.. days
STATISTICAL DETAILS
SEX 76 1
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME +
Roce Barrett
HUSBAND'S NAME
Terance M. Inmay
BIRTHPLACE Lowell
NAME OF FATHER Patrick Barrett
BIRTHPLACE
OF FATHER#
Ireland
MAIDEN NAME OF MOTHER Jane Flynn
BIRTHPLACE
OF MOTHER #
ireland
OCCUPATION none
INFORMANT § m. & Courtney
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
De Patrick bem Lowell July 25 1904
UNDERTAKER
ADDRESS
201
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
(CITY OR TOWN.)
Rose Mc innen
1144.
.Registered No.
Death
5
34
.190 4
& d.6 Dirwell + Sono 324 Market Q " Name of cemetery,
N
٠٠ ٠.٠
COMMONWEALTH OF MASSACHUSETTS
202
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Calvin f.
Prince
Registered No.
55
Place of )
Death * S
north Chelmsford mass
Date of l
...
Death
aug
4
.190 7
5-0
29
.months ..
.days
STATISTICAL DETAILS
SEX
male
COLOR
white
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
married
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE # Bradford mass
NAME OF
FATHER
Henry.
2
rince
BIRTHPLACE
OF FATHER#
Salem mass
MAIDEN NAME OF MOTHER mary J. Jenkins
BIRTHPLACE
OF MOTHER #
Laurence mass
OCCUPATION Painter
INFORMANT § Widow
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL Riverside Cemetery aug/1 190 7
UNDERTAKER 4 ADDRESS
b.m. Young ter 33 tres cott Name of cemetery,
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from.
190 ...... to
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 :
Electric Stick
,
.(DURATION). DAYS
Contributory :
... (DURATION) ..
... DAYS
(Signed) AblishMail.Com
My 5 1907 (Address) 219 Central SC-
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
any. 7
190,
07 Edward & Robbing
Clerk
Down
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts calied 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
Residence
Chelmsford Mass Age 37
.. years.
=
COMMONWEALTH OF MASSACHUSETTS
203
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME Rosa.
alma
Clarke
Registered No.
56
Place of )
Death * S Gehelunsford mais
Date of l aug 15
Death 1
Residence
Real Well Road
.. years ..
... months.
.days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACEİ Phulafund Seule
NAME OF FATHER Edward Clark
1
BIRTHPLACE OF FATHER#
Danvers mais
MAIDEN NAME OF MOTHER Thelimone Laman
BIRTHPLACE OF MOTHER # Canada
OCCUPATION
INFORMANT § Father
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
st louth may aug !! 190. Y
UNDERTAKER
ADDRESS
A Archambault 735 hamnar
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Rump. 11, 1907 to. Un4.15 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 :
-
Endefinate
.(DURATION). DAYS
Contributory :
Q( DURATION).
.DAYS
(Signed)\
Auchun G. Scotona .M.D.
Cauq, 15 907 (Address) Clubinsford, Mais,
SPECIAL INFORMATION only for Hospitais, 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
ana 16 1907 Edward Doffin
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.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
190
80
=
COMMONWEALTH OF MASSACHUSETTS
204
RETURN OF A DEATH
FULL NAME : 1726 Place of Death *
Date of Death. aug. 16- 17
Age.
years
3
months
3
days
STATISTICAL DETAIL
SEX
COLOR
As Filé-
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Worth Chelmsford.
NAME OF FATHER
Desiré Deviquy
BIRTHPLACE OF FATHER İ
MAIDEN NAME OF MOTHER
Ulice Whichrand
BIRTHPLACE OF MOTHER #
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL 17
1
.. .... 190 ..
UNDERTAKER
ADDRESS 5% Cheer EL
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from. Curs 16 1907 to buy 16 .. 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 : Maras mus
Contributory
(Signed)
FLgage
.M. D.
190) (Address) Marchelanderd
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 Chung. 17, 1907 Edward , Robbing
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.
+ 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 cemetry.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL.
1
7
CITY OF LOWELL
57
Registered No ..
. (DURATION) .. DAYS
... (1)URATION). .. . DAYS
Tuttina yet moral.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME Lloyd St. Cheney
58
.Registered No.
Place of l
Chelmsford mask
Death * S
Residence
Chelmsford mass
/
.. years ..
8
months ..
7
.. days
STATISTICAL DETAILS
SEX COLOR male white
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE# Chelmsford Inass
NAME OF FATHER Fred a Cheney
BIRTHPLACE OF FATHER$ Claremont-n.t.
MAIDEN NAME OF MOTHER Priscilla Warren
BIRTHPLACE OF MOTHER # Prince Edwardo Isle
OCCUPATION
INFORMANT §
3 Father
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
Pine Ridge Cemetery aug 19 1907
UNDERTAKER
ADDRESS
G.722: Shining theo 33Prescott Name of cemetery,
PHYSICIAN'S CERTIFICATE
1 HEREBY CERTIFY that I attended deceased during last illness, from. ang. 14 190.7 .. to Ing. 17 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 : Cerebral shock.
(DURATION) ..
DAYS
Contributory :
.(DURATION) ... .. DAYS
(Signed)
Amara Itoward
M.D.
Orig. 17 19067 (Address).
Chelmsford Maco
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 Ona 19 1907 Edward . Roffing
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.
Date of l
aug. 17
.190
7
Death
.. Age
205
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
...
COMMONWEALTH OF MASSACHUSETTS
206 Chelmsford
RETURN OF A DEATH
(CITY OR TOWN.) 59
Registered No.
Date of ¿
Death
1
aug 21
197
Death * S
Residence
Chelmsford
· Age .......
87
.years.
.. months.
6
.days
STATISTICAL DETAILS
SEX
Female
COLOR
white
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Widow
MAIDEN NAME +
Susani 9. Baroin
HUSBAND'S NAME t
Charles Perry
BIRTHPLACE #
Concord n.H.
7
NAME OF
FATHER
Hubbard Sarin
BIRTHPLACE
OF FATHER#
Unknown
MAIDEN NAME
OF MOTHER
Unknown
BIRTHPLACE
OF MOTHER
Unknown
OCCUPATION
at home
INFORMANT § S.o. Perry
Filed
aug. 23
07 Edward Rafting
0
Town
Clerk
PLACE OF BURIAL OR REMOVAL !! Pine Ridge Cen Chelucas
DATE OF BURIAL
aug23
. 190.7
UNDERTAKER Walter Perhan
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
on
aux 18
1907 to-
.190 ...... ,
illness, from
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 :
Carebral Hemorrhage
.. (DURATION). FOR
e
.. DAYS
Contributory :
.. (DURATION).
DAY8
(Signed) ....
.... M.D.
.1907 (Address) 329 Westford St, Lowall.
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 placo of death ?.
* Clty or town, street and number, If any, If death occurs away from USUAL RESI- DENCE, glve 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 detalls. |[ Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
FULL NAME
Susan abbott Gerry
Place of 1
Chelmsford
N
-
١
COMMONWEALTH OF MASSACHUSETTS
207
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Laurence Habe Enaney
.Registered No.
60
Place of l
Death * S
North Chelmsford Picasso
Death
Bug 25
190/
.. months. ........ days
STATISTICAL DETAILS
SEX
male
COLOR
- SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME +
HUSBAND'S NAME Ť
BIRTHPLACE #
North Chelmsford
NAME OF
FATHER
BIRTHPLACE
OF FATHER#
Ireland
MAIDEN NAME
OF MOTHER
Mary Jaren
BIRTHPLACE
OF MOTHER #
Ireland
OCCUPATION
ghoulder
INFORMANT §
mrs. McEnaney
PLACE OF BURIAL OR REMOVAL I
DATE OF BURIAL
St Patrick Lowell aug 27
.. 1907
UNDERTAKER
ADDRESS
INche Dermott 70 Gorham
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Nancy 14 1907 to Lay 28 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 : Brights Disease
Exgut south
(OURATION ).
.. OAYS
1.
Contributory :
(DURATION).
.. DAYS
(Signed).
JE Vaney
M.D.
1907(Address).
n. chalter ford
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 7
Filed
China. 27,1907 Edward . Rolfing
Gown 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, givo 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.
2
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
Residence
North Chelmsford 11cass
Age ....
54
.years ..
٠٠
٤
COMMONWEALTH OF MASSACHUSETTS
CITY 208 OF LOWELL
RETURN OF A DEATH
FULL NAME
andrew 26. Carlson
Registered No ..
61
Place of Death *
North Chelmsford
Date of Death ..
Seht 9" 1907
... Age ..
Lf4 years
..
months
days
STATISTICAL DETAIL
SEX
COLOR
Mace w
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Manned
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
Sweden
NAME OF FATHER John Carlson.
BIRTHPLACE OF FATHER Į
Sweden,
MAIDEN NAME OF MOTHER anna Hilson.
BIRTHPLACE
OF MOTHER #
Sweden,
OCCUPATION Iran Hlouldingsin.
INFORMANT § Mrs andrew Carl Son
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
C
7
UNDERTAKER
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ..
aug 22 1907 to Sell-9 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 : ..
nephritis
about nine months
(DURATION) .. DAYS
Contributory
.. (DURATION). ... DAYS
(Signed)
JE Varney
Sept.9 1907 (Address) Herberthabe 2015
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. 11 10 . Edward J Robbing
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. t In case of married or divorced woman, or widow. # State or Court; also city; town or county; if known. § Name and address of person giving staist cal details.
Jahn Wembeck Sommichellonegary.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL.
٨٠٨
COMMONWEALTH OF MASSACHUSETTS
209
/RETURN OF A DEATH mr. Beatmet Herment
(CITY OR TOWN.)
.. Registered No
62
Place of l Atd Barton and Thelia a de bet-16
Death * S
Residence
Old Barton Road
Age
.years ...
months.
13
.days
STATISTICAL DETAILS
SEX Le
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Chemsford Gunter
NAME OF FATHER & L'gaspard Pleurer
BIRTHPLACE OF FATHER# OGammade
MAIDEN NAME OF MOTHER Emelie Hervier
BIRTHPLACE
OF MOTHER #
OCCUPATION
C
INFORMANT § Dfather
PLACE OF BURIAL OR REMOVAL II est fareth
DATE OF BURIAL
190.
ADDRESS
$38
UNDERTAKER ICHchambault Porum
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Jeal -10 1901 to dent16 909, 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 : Cholera redanhint
(DURATION) 5
OAY8
Contributory :
.. (DURATION) .. DAY8
(Signed)
HURochette
M.D.
Sent 16 1907 (Address) 332 Marmeren
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 Sept. 17 1907Eduard . 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. # State or country ; also city, town or county, If known.
§ Name and address of person giving statistical details. || Name of cemetery.
1
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
MARGIN RESERVED FOR BINDING
FULL NAME
.190
Death ) ··· Y
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
=
COMMONWEALTH OF MASSACHUSETTS
210
RETURN OF A DEATH
(CITY OR TOWN.) 63
FULL NAME
.. Registered No ..
Date of l
Sept 19 1907
Residence
.€
Age.
46
.years ...
months.
.days
STATISTICAL DETAILS
SEX
COLOR
7
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE# Inland
NAME OF FATHER Pating Ting
BIRTHPLACE OF FATHER#
Juland
MAIDEN NAME OF MOTHER Ellen Mulcahy
BIRTHPLACE OF MOTHER #
Ruland
OCCUPATION Carpentier
INFORMANT § Mis Catherine Gregan
PLACE OF BURIAL OR REMOVAL IL Of Patings Century
DATE OF BURIAL
1
190.
UNDERTAKER
ADDRESS
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 :
. (DURATION). DAYS
Contributory :
(DURATION) . DAYS (Signed) At. Juletra 86 SuntIS, 1907 (Address) 219 /autority
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 Sept. 20, 1907 Edward . Jobbing 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, givo 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.
Place of )
Death * S North Ghulmotor A muss
Death
-
SINGLE, MARRICO, WIDOWED, OR DIVORCED
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITFOR TOWN.)
FULL NAME
- William Lundgren
Registered No ..
64
Place of l
Mast CheleFord
Death * S
Residence
Met Cheleford
Age.
35
.years ...
10
months.
.. days
STATISTICAL DETAILS
SEX
male
COLOR
white
SINGLE, MARRIED WIDOWED, OR DIVORCED
Married
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACEİ Reesby Sweeden
NAME OF
FATHER
Lundberg Lundgren
BIRTHPLACE
OF FATHER$
Reesby Sweden
MAIDEN NAME
OF MOTHER
Unknown
BIRTHPLACE
OF MOTHER #
Sweden
OCCUPATION
Quarryman
INFORMANT § apel Peterson
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
West Com. W. Cheliford Sept 27
190 ... 7 ....
UNDERTAKER Walter Perham
ADDRESS
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