USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1908-1909 > Part 10
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12
BIRTHPLACE # North Chelmsford Mass
John Mccacholl
OF FATHER$ Canada
MAIDEN NAME OF MOTHER Delving Fizette
BIRTHPLACE OF MOTHER#
Canada
OCCUPATION at home
PHYSICIAN'S CERTIFICATE
190 ... to I HEREBY CERTIFY that I attended deceased during last iliness, from. Mene. 30 may 4 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 : Debility (DURATION). DAYS
Contributory :
.(DURATION) . DAYS
(Signed).
98laisse
M.D./
July 3- .190 ...... (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 9 Edmed . Rolling .190.
Com 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; aiso city, town or county, If known.
§ Name and address of person giving statistical details.
UNDERTAKER Joseph albert
576 heard Name of cem
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
INFORMANTS John Ms Nicholl
PLACE OF BURIAL , OR REMOVALI UtJoseph Cemetery ChatonsFord Man
DATE OF BURIAL
July 5 th 09
ADDRESS
12
664
Date of ¿ July 2/08, 1909
Death *
.
COMMONWEALTH OF MASSACHUSETTS
122
RETURN OF .A DEATH
(CITY OR TOWN.)
FULL NAME
Frederick Zarkin
Place of )
Death *
Church, St Ho Chementund Man Date of
Residence
Church. Sy Mo. Chers Mas Age
2
.. years .. 7
.. months ..
.. days
STATISTICAL DETAILS
SEX Scale.
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME Ť HUSBAND'S NAME t
BIRTHPLACE# no Chemsfact Mars
NAME OF FATHER John. D. Larkin
BIRTHPLACE OF FATHER# Norwich Com
MAIDEN NAME OF MOTHER Margaret. Dumigan
BIRTHPLACE OF MOTHER Na chemofra
OCCUPATION
INFORMANT § Father
PHYSICIAN'S CERTIFICATE
I HEREBY 'CERTIFY that I attended deceased during last illness, from. 190.7 ... to 7 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 : r
1
Primary :
. (DURATION). . DAY 9
1
Contributory :
(DURATION) .... DAYS
(Signed)
M.D.
V my 190 (Address)
SPECIAL INFORMATION only for Hospitals, Institutlons, Transients, or Recent Residents.
How long at
Place of Death ?
. years ..
..................
.months .. .......... .... . days
Where was disease contracted, If not at place of death ?
Filed July 8
190
9 Eduard w Rithing
Clerk
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
atrides
190.
* 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.
4.4
Death 5 ...
July 1 1909
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Edward Larkin
45
Registered No.
Place of )
North chelansford
Death *
S
Residence
North Chelmsford
Age
5
... years.
5
months.
days
STATISTICAL DETAILS
SEX
mule
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME Ť
HUSBAND'S NAME +
BIRTHPLACE + North chulisford
NAME OF FATHER John D. Larkin
BIRTHPLACE
OF FATHER#
nouvick Con
MAIDEN NAME OF MOTHER Margaret Dunningen
BIRTHPLACE
OF MOTHER #
nochemafia
OCCUPATION
INFORMANT § Father
Dechecks July 0 g PLACE OF BURIAL OR REMOVALH DATE OF BURIAL
UNDERTAKER
4
ADDRESS
1
PHYSICIAN'S CERTIFICATE
July 15 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 : Measles
(DURATION)
DAYS
Contributory :
(DURATION) OAYS
(Signed)
Aula
M;D.
190 ...... (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 July 16, .. 190 09 Edward Rotting
Clerk
0
* 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.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
I HEREBY CERTIFY that I attended deceased during last
illness, from ..
190 ..... to ..
Date of ¿
July 15
190g
Death
123
P
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME Heures 1 Inan-
Registered No.
Place of l
Cielandvord Center Maso
Date of ¿
July 23. .
190%
Death .
S
Residence
Che Lunsford Couler 31200. Age
.years.
.. months.
..... .......... days
STATISTICAL DETAILS
SEX
COLOR Mite
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE # Chelmsford / Pass
NAME OF FATHER William Snart-
BIRTHPLACE
OF FATHER$
Negenant.
MAIDEN NAME
OF MOTHER
Flora Lacombe
BIRTHPLACE
OF MOTHER#
Lowell, Ma.11.
OCCUPATION at home
INFORMANT §
Stelleam Snay
PLACE OF BURIAL OR REMOVAL II If yough . lire te Chilroutard.
DATE OF BURIAL
Viele 24
190
UNDERTAKER
7
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY (CERTIFY that I attended deceased during last illness, from Yle 21 1909 to Jule 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 : Cholera Ru fantin
(DURATION).
6
. DAYS
Contributory :
Leute Lot on Pneumonia
-
.(DURATION)
3
.. DAYS
(Signed)
Anten G, Scolonia -
M.D.
Joly 23 1909 (Address).
Chelmsford-Man
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
July 23,
190.,
9 Edward Rotting
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
124
664
Death *
S
1
1
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
STATISTICAL DETAILS
SEX
IF.
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Married.
MAIDEN NAME +
Anna & Johnson.
HUSBAND'S NAME +
Fredk Tisdale.
BIRTHPLACE #
Sweden.
NAME OF
FATHER
August O. Johnson
BIRTHPLACE
OF FATHER#
Sweeden.
MAIDEN NAME
OF MOTHER
Anna Erickson.
BIRTHPLACE
OF MOTHER#
Sweden,
OCCUPATION
House Wife.
INFORMANT §
Fredk. A. Tisdale
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
Springfield, Mass. Aug, 5. 199.
UNDERTAKER GromHealey.
ADDRESS
79 Branch
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY thatLa lod docenced during last
100
ifthese, fr 100 ..... , 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 :
accidental Drowning
(Baptist Pand To. Chelmsford)
.. (DURATION). DAYS
Contributory :
(OURATION)
.. DAYS
(Signed) W. Meigs, M.D. Medical Examiner
.
aug 1,
.190.g. , (Address)
160 therrenack h.
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
ana 2
1909 Edward golfing
Gown
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, glve 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.
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
125 Dr. Chelmsford. (CITY OR TOWN.)
RETURN OF A DEATH
FULL NAME
Anna Signe Tisdale
117
Registered No ..
Place of ?
Baptist Pond, So Chelmsford.
Death * S
Residence
Springfield, Mass.
Age
23
.. years
3
L
.months.
.days
Date of ¿
Aug.
1.
1909.
Death S
126
FORM O.
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
1
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
2 night
Sex, .. Hade Color, die To
Date of Death,
190%; Age,. 83 Years, 8 .Months, .Days.
Maiden Name, { If married, widowed ) or divorced.
Husband's Name,
Single, Married, Widowed or Divorced, ... lamal Occupation,
*Residence, { If out of town, )
¿ also state fully. §
Chilena
Place of Birth, Brookline 4
4 -
*Placc of Death,
David
IDight
Name and Birthplace of Father, Mary Ann Fuller - Lynn- hrad
Maiden Name and Birthplace of Mother,
Place of Interment, (Give name of Cemetery). Rever Side Curatore 10 Chelmsford
Dated at No. Chelmsford.
Geo Mateale.
on Aug, 2. 1909.
Signature and place of business of Undertaker.
Lowell, Mass.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Wrig,
Age, ... Y. .M ... .D.
Place and Date of Death,
died at.
190
Primary, Disease or Cause of Death, # Secondary,
Duration,
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence of Certifying Physician.
M. D.
Date of Certificate,
190
* Give also street and number, if any. | Givo sex of infant not named. If still-born, so state. If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of theacity or town.
Agent of Board of Health.
No.
RETURN OF THE DEATH
OF
at
Date,
190.
Filed, 190.
[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]
SECTION 6. Every householder in whose house a deatlı occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death oecurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after sueh death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
SECTION 11. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.
SECTION 12. Any person having charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordance with section 10, and return it, together with the facts required by section 1, to the board of health or to the clerk of the city or town in which the death oeeurred.
[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]
SECTION 1. No human body shall be buried in a city or town or removed therefrom, until a permit therefor shall have been received from the proper authorities. No such permit shall be issued until a written statement, as required by law, has been furnished, with a physician's certificate of the cause of death. When sueh statement and certificate are delivered to the Board of Health, the board or agent shall forthwith countersign and transmit the same to the clerk of the city or town for registration.
SECTION 5. Penalty for violation not exceeding fifty dollars.
COMMONWEALTH OF MASSACHUSETTS
1.27
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Lowen
Registered No .... 431
Place of }
Tworth Chelmsford mass
Death * S
Residence
north Chelmsford
Age .. years. 5-4 11
... months.
.days
STATISTICAL DETAILS
SEX Inale
COLOR
white
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
married
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE # West Hartford vf-
NAME OF
FATHER
James bowen
BIRTHPLACE
OF FATHER
West Hartford of
MAIDEN NAME
OF MOTHER
Eliza Hazen
BIRTHPLACE
OF MOTHER #
West Hartford of
OCCUPATION Machinist
INFORMANT § Widow
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
West Hartford vf aug 4,199
UNDERTAKER
ADDRESS b. m. Young 33 Prescott Name of cemetery,
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last Illness, from July 29 . 1909 to to lima) 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 :
. (DURATION) . DAYS
Contributory :
.... (DURATION)
DAYS
M.D.
(Signed)
Cum 3, 1909
203 Central 8H
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
any. 3,
1909 Edward ). Rolling
Com
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 ALL NAMES TO BE IN FULL
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
Date of ¿
aug 10/- 1909
Death
-
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME 7 Claves Vernon
Registered No.
1061
Place of ) Death * S ..........
awell Lind Horst
Date of ¿
30.
190
Residence
Highland are No Chelmsford
Age
61
.- years.
months ...
9 days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
mc Cubbin Veter Vernon
BIRTHPLACE # Scotland
NAME OF
FATHER
erque M'lublina
BIRTHPLACE
OF FATHER#
Scotland
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER #
Scotland
OCCUPATION
House keepu
INFORMANT § Mr Brown
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
190 .. (
UNDERTAKER
4 H. Healy
ADDRESS R
79 branch
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that i attended deceased during last illness, from July 21 190 G to July 30 190 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 ;2.
Carcinoma of the Peritoneum
and Omentünk
. (DURATION)
DAYS
Contributory :
ascites
(Signed)
Leslie . Leland
M.D.
July 31
/190 G (Address)
Lowell Youl Houpt
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 aug 2
909
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. ft Name of cemetery.
t
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
128
Death
july
1.0 (DURATION)
. DAYS
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
..
(CITY OR TOWN.)
FULL NAME
"V J.
Registered No.
51
Place of }
Date of ¿
Death
Death
.190
Residence
Age
.. years.
.months
days
STATISTICAL DETAILS
SEX
COLOR ...
SINGLE, MARRIED, WIDOWED, OR. 7- DIVORCED
MAIDEN NAME Ť
HUSBAND'S NAME t
7
BIRTHPLACE #
-
NAME OF FATHER
BIRTHPLACE OF FATHER$
-
. .
MAIDEN NAME OF MOTHER
- -
-
BIRTHPLACE OF MOTHER +
- ...
OCCUPATION
INFORMANT §
-
-
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
190.
UNDERTAKER
ADDRESS
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from 190.9 .. to aug.10 Omg. 14 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 :
Choplexy
(DURATION
4
DAYS
Contributory :
carditis
(Signed)
Amara Howard
M.D.
aug. 14
190.9 .. (Address)
Chelmsford
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 Cung 15 1909 Edward Rollins
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.
Alt Ronnell Dos 324 Marke Name of cemetery.
.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
129
(DURATION) .. DAYS
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
LucyOBrand
Registered No.
52
Place of Į
West thelinford Mack
Death *
1
Residence
1
Age
58
.years ..
26
.. months 19 days
STATISTICAL DETAILS
SEX Улегов
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED Married
MAIDEN NAME +
HUSBAND'S NAME t a Brand
1
BIRTHPLACE # Calias Mano
NAME OF
FATHER
Hashna Facul
achua.
BIRTHPLACE
OF FATHER#
Hampden ME.
MAIDEN NAME
OF MOTHER
Rachida Lama
BIRTHPLACE
OF MOTHER #
Frankfurt ENE.
OCCUPATION
Huse Wife
INFORMANT § LA Byard
PLACE OF BURIAL OR REMOVAL II Unterport
DATE OF BURIAL
aug 19
190.9
UNDERTAKER ADDRESS John A Wemback to Middle
PHYSICIAN'S CERTIFICATE
.. to I HEREBY CERTIFY that I attended deceased during last illness, from 190 ana 17 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 :
anquer Pectoris
Few hours
(DURATION).
DAY 8
Contributory :
.(DURATION). .. DAY8
(Signed).
JE Jamey
M.D.
Cinq 18
1909 (Address)
2 Chalufort
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents. How long at Place of Death ? years .. ................... months. .................. . day
Where was disease contracted,
If not at place of death ?
Filed
Chra 18.
9 Edward & Raffin
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
70/30
Date of ¿
ana 17
1909
Death S
COMMONWEALTH OF MASSACHUSETTS
Chelmsford 13
(CITY OR TOWN.) 53
Registered No.
Place of l
Gast Chelmsford
Death *
5
Residence
59 Whitney Que
Age
78
.years.
.. months. / .days
STATISTICAL DETAILS
SEX Male
COLOR' ,
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Widowed
MAIDEN NAMEt HUSBAND'S NAME t
BIRTHPLACE # Sureden
NAME OF FATHER Carl Pihl
BIRTHPLACE OF FATHER$ Sureden
MAIDEN NAME OF MOTHER Eva B. C Olin
BIRTHPLACE
OF MOTHER #
Sweden,
OCCUPATION Retired
INFORMANT § Victor & Pihl.
PLACE OF BURIAL OR REMOVAL II JEison Cemetery
DATE OF BURIAL Cur 23 1904
ADDRESS
UNDERTAKER B. Currier to 68 Prescott in
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. aug 17, ... 190.9.to Guy. 21, 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 :
Cardiac Dascase
Indefinite
Contributory :
Cerebral hacenhog i:
1 day
.(DURATION). .DAYS
(Signed).
Antry , Scotnia,
M.D.
aug.21, 1909, (Address).
Chelmsford, mars.
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 any, 21, 1909. Edward S, 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 detalls, ILName of cemetery.
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
RETURN OF, A DEATH
FULL NAME
Martin
6 )ihl
Date of l
auf 21
.1909
Death )
(DURATION). ... DAY6
132
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
8 Overett Richardson tiles
FULL NAME
Place of 2
Chelmsford Dass.
Death *
5
Residence
Chelmsford mare
Age
26
.. years
~
.months 28 .days
STATISTICAL DETAILS
SEX
male
COLOR
White
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME 1 HUSBAND'S NAME +
BIRTHPLACE#
Jerhar Maine
NAME OF
FATHER
Eben Files
BIRTHPLACE
OF FATHER+
Borham Mame
MAIDEN NAME
OF MOTHER
lilly Richardson
BIRTHPLACE
OF MOTHER #
Burlington Allame
OCCUPATION
Printer
INFORMANT § Eben Files
PLACE OF BURIAL OR REMOVAL II
Forfatherd Cemetery
Chelmsford Mars.
DATE OF BURIAL
aug. 14
9
.. 190.
UNDERTAKER
Walter Perham
ADDRESS
Chelmsford
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last iliness, from 1905 to Quy 12 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 :
Spinal myelitis
4 years
(DURATION). DAY9
Contributory :
.( OURATION) .DAY9
(Signed)
Camara Howard
M.D.
Jenny 14, 1909 (Address)
Chelmsford
SPECIAL INFORMATION only for Hospitais, Institutions, Transients, or Recent Residents.
How long at
Piace of Death ?
years.
days
months.
Where was disease contracted,
If not at place of death ?
Filed
Aug, 14,1909 Edward . Rolfing
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, Il Name of cemetery.
MARGIN RESERVED FOR BINDING
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
Chelmetra
(CITY OR TOWN.) 54
Registered No.
Date of Į
Они 12,
Death
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
55
FULL NAME
Place of ì
Death *
Residence
Age
.years.
........ months ..
........
.days
STATISTICAL DETAILS
SEX
COLOR
Thite
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Sir.2¢
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE # North Chelmsford Mar.
NAME OF
FATHER
P.trich J. Ready
BIRTHPLACE
OF FATHER$
MAIDEN NAME
OF MOTHER
Varer Ol Hair
BIRTHPLACE
OF MOTHER #
OCCUPATION
INFORMANT § Sister Fre. Ichn W. Grady Jr.
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
st. Patrick; der standing
190.47 ..
UNDERTAKER
ADDRESS
324 Manget St.
PHYSICIAN'S CERTIFICATE
I HEREBY, CERTIFY that I attended deceased during last
illness, from ...
July
1909 to Cinq 28 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 :
. (DURATION) DAYS
Contributory :
(DURATION) DAYS
(Signed)
M.D.
lucr 909 (Address)
203 Contrar JL
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
ang. 28,
.. 190.
9 Edward . Roffing
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
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.