USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1908-1909 > Part 12
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How long at
Place of Death ?
. years.
.. months ..
................ days
Where was disease contracted,
If not at place of death ?.
Filed
Oct. 30
.190
og Edward . Poffing
Comm
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, glve its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
# State or country , also city, town or county, If known.
§ Name and address of person giving statistical detalis. Il, Name of cemetery.
14/
Chelmsford
(CITY OR TOWN.) 69
FULL NAME
Loseve Laforest
Willis
Registered No.
Place of )
Chelmsford, mais
Date of
1 Oct 29.
1909
Death * S
Death
Residence
24 Print Works Manchester U.H
Age
34
.years.
months 29 days
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Jesse H. Parker.
Place of l
Billerica It. Chelmsford Center.
Death *
5
Residence
Billerica St. Chelmsford Center Age
66
.years.
10
29
.months.
.days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Married.
MAIDEN NAME + HUSBAND'S NAME
BIRTHPLACE # Lowell. Mars.
NAME OF
FATHER
Thomas Parker.
BIRTHPLACE
OF FATHER#
Bedford , Mase .
MAIDEN NAME
OF MOTHER
Alma Goodnow.
BIRTHPLACE
OF MOTHER #
Unity, N. H.
OCCUPATION
Moulder
INFORMANT §
Mne Philena b. Parker.
PLACE OF BURIAL OR REMOVAL II Edson Cemetery.
DATE OF BURIAL
Nov. 5
. 190.2 ....
UNDERTAKER
Geometraley.
ADDRESS
79 Branch St.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that i attended deceased during last illness, from 001.29 190.9 ... to nov. 2 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 : Pneumonia
(DURATION).
4
DAYS
Contributory :
Endocarditis -
(Signed).
amaras toward
(DURATION) ... DAY 8
M.D.
nov. 2 1909 (Address).
Chilmatrod Maro.
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
Nov. 2
09 Edward I Patting
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 clty, town or county, if known.
§ Name and address of person giving statistical detalls. I{ Name of cemetery.
Lowell, Mace.
148 Chelmsford Center (CITY ØR TOWN.)
70
Registered No.
Date of ¿
Nov, 2
1909
Death
1
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME nancy
Sane Stetson
.Registered No.
431
Place of
north Chelmsford maso
Death
S
Residence
north Chelmsford Mass
Age
67
.years
8
months.
265
.days
STATISTICAL DETAILS
SEX
fernale
COLOR white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
married
MAIDEN NAME Ť nancy & Duro
HUSBAND'S NAME + George G. Stetson
BIRTHPLACE #
north Chelmsford. mars
NAME OF FATHER Thomas Durant Momas
BIRTHPLACE OF FATHER+
Chelmsford masz.
Contributory :
.(OURATION). .DAY8
(Signed).
JE Varney
M.D.
21 childerten
1
190 ... (Address)
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 vov.6
09 Glmandy, Hoffe
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.
33 Prescott ILName of cemetery,
PHYSICIAN'S CERTIFICATE
.to nor 4. 1909 I HEREBY CERTIFY that I attended deceased during last illness, from 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 :
Freometer alexia
several years
(DURATION) . DAYS
MAIDEN NAME
OF MOTHER
Elizabeth Marshall
BIRTHPLACE
OF MOTHER #
Unknown
OCCUPATION at- home
INFORMANT §
Husband
PLACE OF BURIAL OR REMOVAL Il
DATE OF BURIAL Riverside Cemetery Chelmsford nov 7, 1909
UNDERTAKER bim, young
ADDRESS
149
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
Date of l
nov 4 . 1909
Death S
ו
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
STATISTICAL DETAILS
SEX
Male
COLOR
White
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE#
Westferd Mass.
NAME OF
FATHER
John F. Callahan
BIRTHPLACE
OF FATHER#
Lewell Mass.
MAIDEN NAME
OF MOTHER
Annie Bradley
BIRTHPLACE
OF MOTHER#
Ireland
OCCUPATION Operative
INFORMANT §
Father
PLACE OF LeWeri Mass St. Patrick's Cemetery
DATE OF BURIAL
Nev. 9th
9
190.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
1909 to
illness, from
nor /
nor 7
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 :
on monary tuberculosis
about one year
.. (DURATION).
DAYS
Contributory :
.(DURATION) . DAYS
(Signed)
nor?
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 ?.
.
Filed
100.8
190,
9 Edward). Rolling
01 Com
Clerk
* City 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.
ADDRESS FRDonnell Sous 24 Mackerel Some of cemetery.
Lowell.
....
Place of )
North Chelmsford
Date of l
Nov. 7, '09
190
Residence
11
"
Age
23
-
-
.months.
.days
.years.
Chelmsford
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Arthur Callahan
.Registered No.
72
Death * S
Death
UNDERTAKER
COMMONWEALTH OF MASSACHUSETTS
150
M.D.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Growth Veale.
Registered No
Place of
Quigley Ave No. Chelmsford.
Death *
Residence
No. Chelmsford.
Age
2
.years.
.months.
21
days
STATISTICAL DETAILS
SEX
M.
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED Singles
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE+ Lowell, Mason
NAME OF FATHER Joseph Veale.
BIRTHPLACE OF FATHER $ Englands
MAIDEN NAME OF MOTHER Ellen Mitchell.
BIRTHPLACE OF MOTHER $ England.
OCCUPATION Nones
INFORMANT § Joseph Veale.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Nov 4 nov 8 .190 1909 to. .... 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 : Congenital Heart Queuss
(DURATION) .. ......... DAYS
Contributory :
(DURATION) DAY8
(Signed)
James I Haban
M.D.
1901 (Address) No 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
190, ....
Edward Volting
Clerk
PLACE OF BURIAL OR REMOVAL !! Riverside Cemetery. No. Chelmsford
DATE OF BURIAL
Nov. 10. 1909.
UNDERTAKER
ADDRESS
79 Branch St.
* 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.
Sowell, Mass.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
151 No. Chelmsford GITT OR TOWN
73
Date of l
Nov. 8
190 9
Death
MARGIN RESERVED FOR BINDING FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
STATISTICAL DETAILS
SEX
male
COLOR
white
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
le doved
MAIDEN NAME Ť
HUSBAND'S NAME +
BIRTHPLACE # acton mass
NAME OF
FATHER
Jonathan Wheeler
BIRTHPLACE OF FATHER$ action mass
MAIDEN NAME
OF MOTHER
Edith Down
BIRTHPLACE
OF MOTHER #
action mo
OCCUPATION Retired
INFORMANT § Euro Annie
Folsona
PLACE OF BURIAL OR REMOVAL II Esdoorn Cemetery
DATE OF BURIAL Nov 23, 1909
UNDERTAKER Com. young
ADDRESS 33 Prescott
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
ilnose, 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 :
Juicide
(Quetel That wound of Brain)
(DURATION) .. DAYS
Contributory :
(DURATION).
.DAY8
(Signed)
W Meine M.S. Medial Examen
.
.M.D.
har 20
1900 ... (Address).
160 Thewrack to.
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
Nov.2.3.
199 Cobrard ., Polifine
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 statisticai detalls. il Name of cemetery.
ALL NAMES TO BE IN FULL
152
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A, DEATH
(CITY OR TOWN.)
FULL NAME Place of )
Death *
5
East Chelmsford mass
Date of ¿
You 20 1909
Death S
Residence
Chelmsford mass
85
Age
.years.
-.......... months ..
-
.... .....
.days
Wheeler
Registered No.
H31
153
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
(CITY OR TOWN.) 1642
Place of }
Death
Lowell Gene Hasst
Residence
No Chelmsford mars,
Age
43
.. years
months ..
days
STATISTICAL DETAILS
SEX
M.
COLOR
٩
-
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
m,
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE #
Freland.
NAME OF
FATHER
John Helsh
BIRTHPLACE
OF FATHER#
Ireland
MAIDEN NAME
OF MOTHER
Sarah Him
BIRTHPLACE
OF MOTHER +
Ireland,
OCCUPATION
d'ireman
INFORMANT § Mas Sim Welsh.
PLACE OF BURIAL OR REMOVAL !!
Nocheinuford,
DATE OF BURIAL
NON 21
190 9
UNDERTAKER
f. a Hembeck
ADDRESS
forudaliser et
PHYSICIAN'S CERTIFICATE
| 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 :
Nephritis
Contributory :
Peritonitis
(DURATION).
DAYS
JL Gages
1
(DURATION)
DAYS
.M.D.
(Signed)
nov 19
190 ... (Address)
100 Branch It.
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 Nes 22
1909
City
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 marrled 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 ALL NAMES TO BE IN FULL
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
FULL NAME
Killian
Welsh
Registered No.
Date of ¿
nw 19
Death
S
199
COMMONWEALTH OF MASSACHUSETTS
154
RETURN OF A DEATH
(CITY OF TOWN.)
76
FULL NAME
Registered No.
Place of l
no Chemotard
Death *
5
Residence
Ho Chemsfind
Age
.. years.
.. months.
.days
STATISTICAL DETAILS
SEX
Female
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME t
HUSBAND'S NAME t
BIRTHPLACE # no themefad
NAME OF FATHER John 9. Parkin
BIRTHPLACE
OF FATHER#
Munich Como
MAIDEN NAME OF MOTHER Margaret Eakin Dungan
BIRTHPLACE
OF MOTHER$
The chemsfeld
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL-II
DATE OF BURIAL
Zur2.
. 190 ..
UNDERTAKER
ADDRESS
/
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from.
No 24 190 7 to
Nov 24 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 :
Tomatina Birtho
(DURATION). . DAY8
Contributory :
(DURATION). .. DAYS
(Signed).
tas y Hoban
M.D.
Nov24
.190 ..... (Address)
No Chelmsford
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
Nov. 26
.1909 Edward Robbing
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, glve Its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
# State or country ; also city, town or county, If known.
§ Name and address of person giving statistical detalls, Il Name of cemetery.
0
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
Still Dor
Date of
Nav 24 1909
Death
COMMONWEALTH OF MASSACHUSETTS
155 Chelesford
(CITY OR TOWN.)
FULL NAME Still Born Munrevan
2%
Place of l
Adams St. North Chelmsford
Death * S
Death 1
Residence
Age
.. years
.days
STATISTICAL DETAILS
SEX
Male
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED Single
MAIDEN NAME t
HUSBAND'S NAME t
BIRTHPLACE # North Chelmsford
NAME OF FATHER
Patrick Mungevan
BIRTHPLACE OF FATHER
Ireland
MAIDEN NAME
OF MOTHER
Ne llis Carey
BIRTHPLACE
OF MOTHER#
Ireland
OCCUPATION
INFORMANT §
Father
PLACE OF BURIAL OR REMOVAL !!
St. Peter's Cemetery
DATE OF BURIAL
Nev. 3I
9
190.
UNDERTAKER,
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from.
190
.. to 190 .... 2, 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 :
Deuts .
.(DURATION). . DAYS
Contributory :
(DURATION). . DAYS
(Signed)
James & Human
.M.D.
Mar24
190 ...... (Address)
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
grc./
1909 Edward S. 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, glve Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. # State or country; also city, town or county, if known.
§ Name and address of person giving statistical detalis. Il Name 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
Registered No.
Date of ¿
pro 2 9 1909
1
COMMONWEALTH OF MASSACHUSETTS
156
Lamele
(CITY OR TOWN.)
FULL NAME
Many M. Winship
Registered No.
Date of l
DO 1,
1900
Death S
6
.months.
7 days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME + Many M. March
HUSBAND'S NAME + Isaac Winship
BIRTHPLACE # ashley, Mass.
NAME OF
FATHER
Geremiala W. March
BIRTHPLACE OF FATHERI ashley Mass.
MAIDEN NAME
OF MOTHER
Rebekah Howard
BIRTHPLACE
OF MOTHER +
ashby Mass
OCCUPATION Horsebreken
INFORMANT §
M. H. Winship
PLACE OF BURIAL OR REMOVAL II Pepperell Mars
DATE OF BURIAL
Dec, 3
·f. 190.9.
UNDERTAKER
LiQ Neenbeck
ADDRESS
So Middr. St.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that + att
nded deceased during last
ilinesoy from
190
190 ..... ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
acciden
Primary :
(Fall den fleurs)
(DURATION) ........
DAYS
Contributory :
Fracture Skull
(Taver (Base() RATION)
. DAYS
(Signed)., & meighths. Medical Examiner M.B.
.19 .... (Address)
160 thenwork 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
Arc, 2
199 Edward J. Bobbing
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
Place of } Wept Chelms. Mars
Death * S
Residence
West Chelmo. Mars.
Age
86
years ..
RETURN OF A DEATH
108
10
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Place of )
Refersfor Mass
Death *
1
Death
Residence
Age
64
.years ..
.months.
.. days
STATISTICAL DETAILS
SEX
Male
COLOR
White
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME t HUSBAND'S NAME Ť
BIRTHPLACE# Canada
NAME OF
FATHER
BIRTHPLACE OF FATHER# Canada
MAIDEN NAME
OF MOTHER
Warce Dage
BIRTHPLACE
OF MOTHER$
Canada
OCCUPATION Labar
INFORMANT §
Forte
PLACE OF BURIAL OR REMOVAL# Joseph comeley Veghelmotor Mass
DATE OF BURIAL
DEc. 7
1909
UNDERTAKER
Joseph Albert
ADDRESS
57 le heever
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from.
Dex 1 1909 to Due 4 190.9 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 : Enteritis
Contributory :
(DURATION) . DAYS
(Signed).
LURachelto
M.D.
De 6
190.2 ... (Address)
732 Marine2
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
ДЕс. 7
00 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 ] als@ city, town or county, If known. § Name and address of person giving statistical details. Name of centery A Sales. Ret.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
Lucien Heartin
swell
Registered No ...
664
Date of December 201909
.(DURATION)
DAYS
9
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
.ra 158
Chelmsford
(CITY OR TOWN.) 80
Registered No.
Date of Dec. 21
1909
Death * S
Death
.. years
8
.months.
6
.days
STATISTICAL DETAILS
SEX 7
COLOR
OR
SINGLE, MARRIED,
WIDOWED,
DIVORCED
Married
MAIDEN NAME +
Charlotte Word
HUSBAND'S NAME t frank B Hough
BIRTHPLACE #
Prince Edward Island
NAME OF
FATHER
- Word
BIRTHPLACE
OF FATHER#
P. E. Q
MAIDEN NAME
OF MOTHER
Eninom
BIRTHPLACE
OF MOTHER#
P. E.l.
OCCUPATION
Housewife
INFORMANT §
trauk B. Hough.
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
Edson Leem Lowell Dec. 23
9
UNDERTAKER
Wallen Berham
ADDRESS
Chelmsford
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from Dec 21 190.9 .. to Dec- 211909, 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 : asthma ٠
(DURATION).
Years
Contributory :
Cardiac failure .
.(DURATION) . DAY8
(Signed)
Amara Howard
M.D.
Dec 22 1909 (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 ?.
Filed
DEC 23
1909 Award S. Mobbing
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.
RETURN OF A DEATH Charlotte R. Hough
FULL NAME
Place of l
lehelms ford. Mars
Residence
Age
44
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Place of )
Lowell Hasht.
Date of l
De 24
190 9
Residence
Chelmsford mars
Age
30
.years
11
months.
29
days
STATISTICAL DETAILS
SEX
COLOR
It.
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME Ť HUSBAND'S NAME +
BIRTHPLACE #
Lowell mari
NAME OF
FATHER
Josepho adams
BIRTHPLACE
OF FATHER#
Lowell mars,
MAIDEN NAME
OF MOTHER
Janny Pearl
BIRTHPLACE
OF MOTHER +
Lowell mars
OCCUPATION at Home
INFORMANT § Sister
PLACE OF BURIAL OR REMOVAL !! 17 prefati Correcting Chelmsford Mais
DATE OF BURIAL
Dic 26
1909
UNDERTAKER
albert N. Birby
ADDRESS
24 Jackson
DA
Il Name of cemetery.
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from 21011 190 G to 210 24 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 :
Typhoid Jevu
(DURATION).
19
. DAYS
Contributory :
(Signed)
6 3 Simpson
M.D.
Die 24 1909 (Address)
Lowell Hosp
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death 7
. yearş.
months
13
days
If not at place of death ?
Filed Dec 28 00 G Girard Vadman.
190 ..
-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 detalls.
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
159
Grace V. adam
.Registered No.
1827
Death *
5
Death
(DURATION)
.. DAYS
Where was disease contracted,
Chelmsford mars.
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