USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1906-1907 > Part 6
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[] Name of cemetry.
COMMONWEALTH OF MASSACHUSETTS
En Howard CITY OF 129 LOWELL
Registered No .. 70
.(DURATION).
3 masary
How long at
TOMEET
LAH
130
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
James Ru Bowley
Registered No ..
1624
Place of )
Lowell Gen, Daaph
Date of }
Oct. 30
190
6
Death * S
Residence
Chelmsford mars.
Age
53
... years.
.. months ..
days
STATISTICAL DETAILS
SEX
m.
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
1
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE #
Jumple me
NAME OF
FATHER
Hilliam Bowly
BIRTHPLACE
OF FATHER#
New Sharon me
MAIDEN NAME
OF MOTHER
may Wilkins
BIRTHPLACE
OF MOTHER #
Hilton n. M
OCCUPATION
Farmer
INFORMANT § E. G. Blais dell.
PLACE OF BURIAL OR REMOVAL !!
Dr Patrick bem. Lowell
DATE OF BURIAL
Nov.1 190
00 6
UNDERTAKER
Hatte Durham!
ADDRESS
Chehanford.
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended/deceased during last illness, from Oct. 28 190 to. Och. 30 .1906 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 : Uncommonnia
Contributory :
DURATION )
.. DAYS
.M. D.
Oct. 30 190 6 (Address) Lowell Gul, Hashe.
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
ـرفـ
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.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
Death
1
. (DURATION).
.. DAYS
(Signed)
Merritt G. Lang
٠٠
131
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME benjamin Mi Fletchers
.Registered No.
72
Place of )
So Chelmsford , raw
Date of ¿
Death
nov. 10.
........... 190 2
Death * S
=
Residence
Age.
3
0
... years.
.. months.
12
.days
STATISTICAL DETAILS
SEX
rnale
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME }
BIRTHPLACE #
Albaniy, R. of.
NAME OF
FATHER
Jonathan. Htetcher
BIRTHPLACE
OF FATHER#
Greet, maine,
MAIDEN NAME
OF MOTHER
Abigail stead.
BIRTHPLACE
OF MOTHER #
OCCUPATION
Farmer
INFORMANT § mrs. Burton Lander
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Det. 31 1906 to nov 10 1906 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 : Pericarditis
. (DURATION) 3
DAYS
Contributory :
Enfeebled Condition
.(OURATION)
.OAYS
(Signed)
WJ. Sleeper fer OV, Wells M. D.
11-10 1906 (Address).
Westford mass
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
trav. 12
1906
Edward J. Agthing
Clerk
* City or town, street and number, if any, If death occurs away from USUAL RESI- DENCE, give facts called for under "Speclal Information." If in a Hospital or Institution, give its NAME instead of street and number.
t In case of married or divorced woman, or widow.
# State or country ; also city, town or county, If known.
§ Name and address of person giving statistical details. Il 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
Hart Ford Cemetery
Sochelmsford mat's.
1
UNDERTAKER
Don't P. Buarn
DATE OF BURIAL
nov. ict
...... 190 .... ...
ADDRESS
Sm. Chelinford
rijass.
١
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
7
FULL NAME
Place of Death *
un centre
Date of Death
Age 44 ... years ..
... months days
STATISTICAL DETAIL
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME 1
BIRTHPLACE #
1
1
-1
NAME OF FATHER
BIRTHPLACE. OF FATHER #
MAIDEN NAME OF MOTHER
BIRTHPLACE OF MOTHER # (
OCCUPATION
-2
INFORMANT &-
Mil homal - Dolorauch
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from .. 190 .... to 2100.11/2006. 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 : Epileptifor Convulsions ~
.(DURATION) .. DAYS
Contributory abmit Two y
Top. (DURATION). ... DAYS
(Signed)
Arthur Les Sorbona
Mon, 12, 1906 (Address) Chelmsford Mes,
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
Nov. 13
... 1906
6. Edward. Potting
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.
11 Name of cemetry.
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
UNDERTAKER Oliver Dalton Wakefield
ADDRESS
132
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
Registered No .. 73
How long at
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
CITY 133 OF LOWELL 74
FULL NAME georgiana Bruno
Registered No ..
Place of Death *
Chelmsford Mass
Date of Death
November 14 Th 1906
Age
00.
23
years
months days
STATISTICAL DETAIL
SEX Female White
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME + Georgiana Landry
HUSBAND'S NAME + Amable Bruno
BIRTHPLACE ± Carrada
NAME OF FATHER
Felic Landry
BIRTHPLACE OF FATHER I
Canada
MAIDEN NAME OF MOTHER Marie Lacombe C
BIRTHPLACE OF MOTHER # Canada
OCCUPATION
House keeper
INFORMANT § a Bruno
PLACE OF BURIAL OR REMOVAL !!
Ir lowelsh
Cem. Nov 16
.... 190 .. 6
Joseph aller 57 Cheever
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from.
As 13 190 6 to No 14 190 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 : Appenditation
.(DURATION). DAYS
Contributory
(Signed)
R. Mignance-)
.M. D.
Norsk 100 G (Address) 534 Merk
SPECIAL INFORMATION only for Hospitals, Institucions, 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 Mar. 15 1906 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.
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.
1| Name of cemetry.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL.
DATE OF BURIAL
... (DURATION) .. . DAYS
Преднали-
COMMONWEALTH OF MASSACHUSETTS
134
CITY OF LOWELL 75
RETURN OF A DEATH
FULL NAME Susanna. D. Randlett
Place of Death *
Chelmsford. macer
Date of Death
Age 87. years.
months .days
STATISTICAL DETAIL
SEX 7
COLOR
Sar.
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME + Susanna Clark
HUSBAND'S NAME + George R. Randlet
BIRTHPLACE #
Solow.
the .
NAME OF FATHER Unknown
BIRTHPLACE OF FATHER ± I. H
MAIDEN NAME OF MOTHER
BIRTHPLACE OF MOTHER #
OCCUPATION
C.D. Home
INFORMANT §
PLACE OF BURIAL OR REMOVAL # 2 Ringarpide Chelmsford Cemeter. Nov 17th 6 .... 190.
UNDERTAKER
ADDRESS
58 Prescott St.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
Illness, from .. Fur 13 1906 to For. I 90 6.
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). DAVS
Contributory
... (DURATION). . DAYS
(Signed)
.. M. D.
Nov. 16 190 (Address).
25% Curral 8 2
SPECIAL INFORMATION only for Hospitals, Institucions, 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 Nov. 16 190 6. Comand Rotting 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.
# State or Country ; also city, town or county, if known.
§ Name and address of person giving statistical details.
|| Name of cemetry.
De Poster.
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
DATE OF BURIAL
Registered No.
COMMONWEALTH OF MASSACHUSETTS
GIFY 135
LOWELL
FULL NAME
Place of Death *
Main St North Chillingrel Maas
Date of Death (
November 30, 1906.
Age.
61
years
months
days
STATISTICAL DETAIL
SEX Male
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Ireland
NAME OF FATHER
Jolie@Common
BIRTHPLACE OF FATHER ±
Prelauch
MAIDEN NAME OF MOTHER Eleen Mooie
BIRTHPLACE OF MOTHER #
Julauch
OCCUPATION
hon Woulder
INFORMANT § Ellen é C'Common
PLACE OF BURIAL OR REMOVAL !! Tonili Mass. Strates
DATE OF BURIAL Dsc 34. 9
.. 190.
UNDERTAKER
theo Dornel Sons
ADDRESS Lomel Mass
PHYSICIAN'S CERTIFICATE
I HEREBY, CERTIFY that I attended deceased during last
illness, from ..
1905 Hor 30
6
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 :
Hemiplegia
seventeen mande
(DURATION) DAYS
Contributory
(Signed)
JE Vany
.(DURATION). .. DAYS
+ .... M. D.
Dec/ 1906 (Addres
..
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
DEo. 3
190
6. Eduard J . Bobbing
0
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 cemetry.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL.
RETURN OF A DEATH
Registered No.
76
Fin
6
COMMONWEALTH OF MASSACHUSETTS
CITY 1.36 OF LOWELL
77
Place of Death *
East Chelmsford
Date of Death
December 5th 1906 Age 32
years.
-
months
5-
days
STATISTICAL DETAIL
SEX
COLOR
SINGLE, MARRIED, WIDOWED, QR DIVORCED
married
MAIDEN NAME + Edith a. Boughton
HUSBAND'S NAME + alvah It. nickles
BIRTHPLACE # England
NAME OF FATHER William Boughton
BIRTHPLACE OF FATHER İ England
MAIDEN NAME OF MOTHER Harriet Your
BIRTHPLACE OF MOTHER # England
OCCUPATION
at home
INFORMANT § Husband
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL Edson Cemetery Dec 9, 0 6
ADDRESS
UNDERTAKER I'm. Young to 33 Prescott 1
PHYSICIAN'S CERTIFICATE
I HEREBY
CERTIFY that I attended deceased during last
illness, from ..
DEc.1
1906 to DSC, 4 190 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 Pneumonia and Iscaruan /
... (DURATION). DAYS
Contributory
.. (DURATION) News ... DAYS
(Signed) ... Arthur Si Scoberia .M. D.
Arc.8 ... .... 1900(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 DEc.8
.19066
of Eduard Sa o fim
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 2 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 FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL.
RETURN OF A DEATH
FULL NAME
Edith
. a
nickles
Female white
COMMONWEALTH OF MASSACHUSETTS
137
Chelmsford
RETURN OF A DEATH
...
(CITY OR TOWN.) 78
FULL NAME
Mary . M' Enaney
.. Registered No.
Place of )
North Hohelangford
Death * S
Residence
Arith Chelmsford
Age ..
110
... years.
.. months.
........ days
STATISTICAL DETAILS
SEX
VEinale
COLOR
"White
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME Ť
HUSBAND'S NAME t
BIRTHPLACE֏
North Chelmsford
NAME OF-
FATHER
"Peter Mc Enany
BIRTHPLACE
OF FATHER#
Ireland
MAIDEN NAME
OF MOTHER
Roze a. M " Enany
BIRTHPLACE
OF MOTHER#
reland
OCCUPATION Home Work
INFORMANT § Sister
PLACE OF BURIAL OR REMOVAL II
St. Patrickes Com Korall
DATE OF BURIAL
DEC. 10,
.. 1906
UNDERTAKER C. H. Molloy
ADDRESS
Lowell
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from .. DEC. 5 190 6 to DEe.7 1906, 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
.(OURATION). .DAYS
Contributory : Nak HEa East
.. (DURATION) .. .. DAYS
(Signed) amaca Howard
M.D.
DEc. 8
... 190G ... (Address)
Chehusford
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
Dic 10.
....... 90
6 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 detalls. [] Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
Date of l
DEc. 7
.1906
Death
1
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL.
COMMONWEALTH OF MASSACHUSETTS
TX138
-CITY -OF LOWELE
RETURN OF, A DEATH
FULL NAME
Place of Death * Chelmsford Mars
Date of Death July 1906
Age
65
years
3
months
14
.days
STATISTICAL DETAIL
SEX male
COLOR
white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
manuel
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # forwell
NAME OF FATHER Stephen a Column
BIRTHPLACE OF FATHER # C
Sowell
MAIDEN NAME OF MOTHER Larey Riffing
BIRTHPLACE OF MOTHER # chelmsford
OCCUPATION Farmer
INFORMANT § Frank & Crown
PLACE OF BURIAL OR REMOVAL II Sowell Comety
UNDERTAKER Horacedla
ADDRESS 12 Hund St
PHYSICIAN'S CERTIFICATE
I HEREBY
CERTIFY that I attended deceased during last
illness, from ..
.1906, to DECI 1906
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 alisces
Contributory ..
Audrey
Abladder dis
(DURATION).
... DAYS
(Signed)
Torres Martin
.M. D.
DEc/9 1906 ( Address) 19 Gange
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 DEC. 10 06. Eduard J. Robbing
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.
*
DATE OF BURIAL
.... 190
6
79
Registered No ..
.(DURATION).
DAYS
.....
DOYAMI .
COMMONWEALTH OF MASSACHUSETTS
139
CITY OF LOWELL
80
Registered No ..
months
9
days
STATISTICAL DETAIL
SEX fe
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Chelmsford Center
NAME OF FATHER David Bellerose
BIRTHPLACE. OF FATHER Į Carrada
MAIDEN NAME OF MOTHER
almina Menard
BIRTHPLACE OF MOTHER # Canada
OCCUPATION
C
INFORMANT §
Father
PLACE OF BURIAL OR REMOVAL II St- Patrick
DATE OF BURIAL aug 1219
UNDERTAKER ADDRESS 738 A Archambault hermack"
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last ness, Muy 14 1906 to My 22 190 4 that to the best of my knowledge and belief death occurred on the dlate stated above, and that the CAUSE OF DEATH was of follows : Primary : .. Bougentat Debility
Contributory
.(DURATION). . DAYS
(Signed)
FURochette
.M. D.
clay 22 1906 (Address) 734 Atenuachi
SPECIAL INFORMATION only for Hospitals, Institucions, Transients, or Recent Residents.
Former or Usual Residence .. . Place of Death ?. .Days
Where was disease contracted, if not at place of death ?..
Filed ang. 22, 1906 Edward Sobomz 1
0
1
varón 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
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL.
FULL NAME
Place of Death *
Date of Death cung x22
RETURN OF A DEATH Marie B.J. Bellerose Chelles ford Center
1906 Age
years
(DURATION) ........ .. DAYS
How long at
٢٠٠
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
CITY 40 OF LOWELL
Registered No ..
81
FULL NAME
George ride
Place of Death *
Forthe Chelmsford
Date of Death
Llec. 10, 1900.
Age ..
8.5 years
months days
STATISTICAL, DETAIL
SEX
male
COLOR
White
SINGLE; MARRIED, WIDOWED, OR- DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Francestown n. A.
NAME OF FATHER William Hud
BIRTHPLACE OF FATHER + Conventre Connecticut°
MAIDEN NAME OF MOTHER alice Marshall
BIRTHPLACE OF MOTHER # Billerica
OCCUPATION
Pattern maker
INFORMANT § Mro. Hurde
PLACE OF BURIAL OR REMOVAL II Riverside Cemeting no. Chelmsford
DATE OF BURIAL Alex. 12, 10 6.
ADDRESS
UNDERTAKER A. a. Weinbeck 80 Med dr. St.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last Dec- 190 6 to Dec 10 190 6 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 of follows : Primary :
1
10
Contributory
(Signed)
JE.Ourney
M. D.
Llec 60 100 (Address) ..
SPECIAL INFORMATION only for Hospitals, Institucions, 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
Edward) Rabbin 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.
11 Name of cemetry.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL.
.(DURATION) ..
. . DAYS
(DURATION). . DAYS
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
STATISTICAL DETAILS
Sex
Color
Female White
Single, Married, Widowed or Divorced
Maiden Name
Tharsile Sangley
TIQVIS NOVIS INST.
Husband's Full Name Leaved Segrou
Birthplace City or Town and State or Country
Canada
YTA
Full Name of Father Unlenoun RECMINE. DON
A
Birthplace of Father Canada
City or Town and State or Country
Maiden Name of Mother Unknown
Birthplace of Mother City or Town and State or Country
Canada
Occupation none
Informant's Name [Person giving statistical details )
City or Town Sisterlaw Street
Place of Burial or Removal Cemetery
Undertaker's Name Address Juinothy J. A Leanely
n cambridge
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from. Lec 4 . 1906 to Llee13 190 6; 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 : (If a soldier or sailor who served in the war of the rebellion both the primary and contributory causes of death must be given.) . Primary : 1
of old age
(Duration)
usapo,
Contributory : \
-
( Duration)
(Signed)
(Address) north Chelen ford.
* How long at
Place of Death ?..
Years ..
Months.
Days
Usual Residence
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Received at office of Board of Health DE XEc 15-
No. of Burial
.. 190 6 Permtt
Edward jaffa.
Form I
Clerk of Board of Health
ETRACEL HON COUNEN 90
Form Click
141
COMMONWEALTH OF MASSACHUSETTS Tour of chemsford -nf-
Hitit
RETURN OF A DEATH
Cambridge 82
FULL NAME & Princeton St h. Chemsford
* Place of
Death Name of Hospital or Institution, if any No
Street
Place of ? 8 Princeton St
Residence
No.
Street
City or Town
{ Date of Dec 13.
Cambridge { Death .190 6
Age 81 Years. Months Days
Tharsile Segrow
. Registered No.
.M. D.
If a married or divorced woman or widow
3
The office of Board of Health will be open for the granting of permits for burial as follows: Saturdays, 8 a. m. till I p. m .; Sundays and Holidays, 12 m. till I p. m .; Other Days from 8 a. m. till 4 p. m.
BE VERY CAREFUL TO FILL ALL BLANKS IN INK
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
142 Cefrelmsford.
RETURN OF A DEATH
FULL NAME
Chas. 7: In Fish
(CITY OR TOWY.) 83
Place of )
Death * S-
South Chelmsford
Death
months.
18.
.days
STATISTICAL DETAILS
SEX A
COLOR-7
W
SINGLE, MARRIED,
WIDOWED, QR
.DIVORCED
MAIDEN ' NAME t HUSBAND'S NAME
BIRTHPLACE# Waterville Me.
NAME OF
FATHER
graphe Fish
BIRTHPLACE
OF FATHER#
Waterville Me.
MAIDEN NAME
OF MOTHER
Sarah Parker
BIRTHPLACE
OF MOTHER#
maine.
OCCUPATION
Blacksmith.
INFORMANT §
Mr. Fish (wife)
PLACE OF BURIAL OR REMOVAL !!
Cart Pour Ceau.
DATE OF BURIAL
lec. 180
190 6
190.
UNDERTAKER
W. Perhans
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Nic. 9 1906 to DEC 16, 1906,~ 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 : a ـير
. (DURATION).
.. DAY8
Contributory :
(Signed)
Antica y Scobana
M.D.
Die. 17 1906 (Address) Chelowfod, Maco.
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 Dec 18 1906 Edward . Nothing
Jour
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If in a Hospital or Institution, give Its NAME instead of street and number.
t In case of married or divorced woman, or widow, # State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
0 || Name of cemetery.
Registered No.
Date of l
Alec. 16
.1906
Residence
Age
46
.years.
...... (DURATION)
. DAYS
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
COMMONWEALTH OF MASSACHUSETTS
CITY 143 OF LOWELL
RETURN OF A DEATH
FULL NAME Hannah
Place of Death * Chelmsford
Date of Death Dec 17, 1906
Age ..
75
years
5-
months
13
days
STATISTICAL, DETAIL
SEX
COLOR Shemale white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
married
MAIDEN NAME +
Hannah Dani
HUSBAND'S NAME + John Wheeler
BIRTHPLACE #
Danville Vermont
NAME OF FATHER Joseph Dane
BIRTHPLACE OF FATHER Į Vermont
MAIDEN NAME OF MOTHER Jane Wheeler
BIRTHPLACE OF MOTHER Vermont
OCCUPATION at home
INFORMANT § Husband
PLACE OF BURIAL OR REMOVAL !! DATE OF BURIAL Derby Vermont Dec 19 00 6
ADDRESS
UNDERTAKER b.m. young ter 33 Rescott
PHYSICIAN'S CERTIFICATE
I HEREBY/ CERTIFY that I attended deceased during last
illness, from.
Nos . 26 190 6 to DEC 16/ 1906;
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 :
Valvular
HEaux
Fardifiante.
.(DURATION). DAYS
Contributory
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