USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1908-1909 > Part 9
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(Signed)
* E Vanagy
M.D.
May 12 1909 (Address)
n chefcontent
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 Inem 12
1909
* 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
Registered No.
Date of l
Death
1
May 12.1909.
Clerk
COMMONWEALTH OF MASSACHUSETTS
108
Chelmsford
(CITY OR TOWN.) 30
Registered No.
Place of 1
chelmsford, Mark.
Death * S
Residence
Boston
Age
67
.years.
6
months.
9 .days
STATISTICAL DETAILS
SEX
Male
COLOR
white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME + HUSBAND'S NAME t
BIRTHPLACE #
Berlin, Mare.
NAME OF
FATHER
Thomas Hall
BIRTHPLACE
OF FATHER#
Leonunstro
MAIDEN NAME OF MOTHER Sauch, Couper
BIRTHPLACE OF MOTHER # Plymouth
OCCUPATION Physician
INFORMANT §
Mo Hale
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. May 14th May 14 .190.9, .... 190.7.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 : leerbral embolism
(DURATION).
1
DAY8
Contributory :
arteriosclerosis
(OURATION) ...... DAYS
(Signed)
amara toward
M.Đ.
Mg 15
190 .. 1 (Address)
Chelimiting
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
Man, 17.
1909 Edward Rotting
Clerk
PLACE OF BURIAL OR REMOVAL II Honest Hil Pers
DATE OF BURIAL
May 17
190 .. 7 ..
UNDERTAKER
Halte Perhan
ADDRESS
Chelmsford
* 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
RETURN OF A DEATH
FULL NAME
Dr. Thomas Hall
Date of
May 14
.1909
Death S
1
$
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD {
ALL NAMES TO BE IN FULL
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME t HUSBAND'S NAME t
BIRTHPLACE# North Theluns ford
NAME OF
FATHER
BIRTHPLACE OF FATHER$ C
)
MAIDEN NAME OF MOTHER Era Lagrande
BIRTHPLACE OF MOTHER North Stradford
OCCUPATION
C
INFORMANT § Fra This
PLACE OF BURIAL, OR REMOVAL II If gareth
UNDERTAKER
ADDRESS
135€
I Archambault services
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from.
.....
190. .to May 15 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 :
atalectares
href hour.
(DURATION).
............ DAY8
Contributory :
Temature auch
(DURATION). DAY8
(Signed)
7 E Varney
.M.D.
may 16 1909 (Address
n. Chelfen?
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 than 17
1909. Edward Rating
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If in a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
# State or country; also city, town or county, If known.
§ Name and address of person giving statistical detalis. Il Name of cemetery.
109
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME Quang Lagrandeur
Place of l
Death * S Marth Che husfard
Date of ¿
Death
May 16
.190
Residence
Age
.years.
months.
1 hour
days
STATISTICAL DETAILS
Registered No ...
3/
1
DATE OF BURIAL
COMMONWEALTH OF MASSACHUSETTS
110
RETURN OF A DEATH
(CITY OR TOWN.)
1
FULL NAME
Place of l
Death * S
Date of l Death May 21 1909.
Residence
1.1.
Age
.. months ..
.days
STATISTICAL DETAILS
SEX male
COLOR White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Lowell maso
NAME OF FATHER Thomas , gridatoal
BIRTHPLACE OF FATHER* England(
MAIDEN NAME OF MOTHER
BIRTHPLACE OF MOTHER # Ferment
OCCUPATION
INFORMANT §
Thomas Budgeford.
PLACE OF BURIAL OR REMOVAL II Ho Chelmsford
DATE OF BURIAL
May 2 3 rd 1909
UNDERTAKER GromHealey.
ADDRESS
79 Branch Sr.
PHYSICIAN'S CERTIFICATE
1 HEREBY CERTIFY that I attended deceased during last illness, from. 190 May13 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 :
Whooping Cough
2 × 3 work
(DURATION) DAYS
Contributory :
.. (DURATION) ......... DAYS
(Signed)
JE Varney
n. Chaleurfest
M.D.
May 22 909 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
. years.
months. .................... . days
Where was disease contracted, If not at place of death ?
Filed may 22 .190., ... Edwards, Robbins
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 detalls. Il Name of cemetery.
-
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
Mark Intasten Registered No. 32
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
STATISTICAL DETAILS
SEX Female
COLOR White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Widowed
MAIDEN NAME + Et Lehanna S. Johnson
HUSBAND'S NAME t Peter M. Schmon
BIRTHPLACE # Sweden
NAME OF FATHER Vil Johnson
BIRTHPLACE OF FATHER#
MAIDEN NAME OF MOTHER Petronella Martinon
BIRTHPLACE OF MOTHER # Burdur.
OCCUPATION
INFORMANT § Ernest. a. Johnsson E Chelonfand
PLACE OF BURIAL OR REMOVAL II Edson Secretary
DATE OF BURIAL May 26 1909.
UNDERTAKER 311/ Saunders
ADDRESS 12 Hands
mmell.
PHYSICIAN'S CERTIFICATE
HEREBY CERTIFY t
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 :
acciden (BON. SI. Ruay)
multiple Traumatisme (Fracture ofSkull Thera Polis Elixo)
Contributory :
(OURATION). .. DAYe
(Signed)
a W. Meigs ME Hedied Examens
Aha, 25 90 (Address)
la Themback h.
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 Thay 26 1909 Gdwand . 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 detalls. || Name of cemetery.
6. Chelmsford.
(CITY OR TOWN.)
33 77.
FULL NAME
Registered No.
Date of ¿
May 23
1909
Death
Death * 5
Place of } 6. Chelmsford
Residence
6. Chelmsford
5%
Age
months ...................... days
.. years
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
Johanna S. Johnson
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Registered No.
Place of )
Date of ¿
Hav 23, 109
190
Death *
5
Residence
Age
T9
years.
... months .......... .. days
STATISTICAL DETAILS
SEX
Female
COLOR
White
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE #
North Chelmsford
NAME OF
FATHER
Ichr 7. Callahan
BIRTHPLACE
OF FATHER$
Lcwoll
MAIDEN NAME
OF MOTHER
Ann Bradley
BIRTHPLACE
OF MOTHER #
Trelard
OCCUPATION
INFORMANT §
Father
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
St. patrick's Cemetery
C
190 ..
ADDRESS
3 24 Market St
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from May 5 190.9 ... to May 23 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 : Pulmonary tuberculosis
one yeah (DURATION). .............. DAYS
Contributory :
(DURATION) .. DAYS
(Signed)
JE Vaney
.M.D.
May 2/19
190 ..... (Address)
7. Cheharfen
SPECIAL INFORMATION only for Hospitals, Institutlons, Translents, 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 Talking
C
Voit 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.
+++ 00 =
§ Name and address of person giving statistical details. Il Name of cemetery.
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
12
Chelmsford
34
Death S
-
UNDERTAKER
113
COMMONWEALTH OF MASSACHUSETTS
CITY OF LOWELL
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Place of l
Novell minhaluz.
Date of l
Death *
Residence
Creio,2) Ferrel ", ILCAL2
14
.. years.
months.
.days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
1
MAIDEN NAME Ť HUSBAND'S NAME +
BIRTHPLACE #
1
NAME OF
FATHER
1
* cander vargérez
BIRTHPLACE OF FATHER# Fort George R. L.
MAIDEN NAME
OF MOTHER
Marta Hilson
BIRTHPLACE
OF MOTHER +
Nova Scotia
OCCUPATION
INFORMANT §
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 :
Intestinal Hangrend
1
Contributory :
parerilazio de 1kl 12221
(Signed)
Ciara Howard,
.M.D.
2 may 21 190 1 (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 Enne 4 1904
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 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 ALL NAMES TO BE IN FULL
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
PLACE OF BURIAL OR REMOVAL II
ine Vidac tum. thelawford
DATE OF BURIAL May 31
190 6
UNDERTAKER Kaller wham.
ADDRESS
1
1
.Registered No.
Death 1
190
9
Ag
1
( DURATION),
DAYS
(DURATION)
.. DAYS
COMMONWEALTH OF MASSACHUSETTS
114
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Place of l
Death *
1
Chelmsford
Centre
Date of
Death
S
Thay
3/1
.190
9
Residence
Chelmsford maso
Age
49
.. years
months.
.. days
STATISTICAL DETAILS
SEX
female
COLOR
white
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
marruce
MAIDEN NAME +
Martha ft.
HUSBAND'S NAME t
Charles J. Searle
BIRTHPLACE#
Concord n. H.
NAME OF
FATHER
David O. Stanyan
BIRTHPLACE
OF FATHER #
Wentworth n. H.
MAIDEN NAME
OF MOTHER
mary
BIRTHPLACE
OF MOTHER #
Warren
OCCUPATION
at-
home
INFORMANT § Husband
PLACE OF BURIAL OR REMOVAL !! DATE OF BURIAL Lowell Cemetery June 2, 1909
UNDERTAKER ADDRESS b.m. young 33 Mescott
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from
يميهوب
490 .... , that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary :
(DURATION) .. DAYS
Contributory :
(Signed).
Antun S. Scolonia,
.. . . DAYS
M.D.
-June 1, 1909. (Adres).
Agy. Brand of Health
Chelo ford mais
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. Edward Koffie 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 marrled or divorced woman, or widow. # State or country ; also city, town or county, if known.
§ Name and address of person glving statistical detalls. !! Name of cemetery.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
martha H. Searle
.Registered No.
431
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
STATISTICAL DETAILS
SEX
Male
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Nashua, N.H.
NAME OF
FATHER
George F. Spaulding
BIRTHPLACE
OF FATHER$
Westford, Mass,
MAIDEN NAME
OF MOTHER
Eliza B. Downing
BIRTHPLACE
OF MOTHER
Piermont, N.H.
OCCUPATION
Blacksmith
INFORMANT §
Mrs. Ella A. Roberts,
sister.
PLACE OF BURIAL OR REMOVAL II Portsmouth, N.H.
DATE OF BURIAL
May .... 17
190 ..
9
UNDERTAKER
A.G.Getchell & Son
ADDRESS
No. Grafton
PHYSICIAN'S CERTIFICATE
1 HEREBY CERTIFY that I attended deceased during last 190. illness, from Apr. 28 .to 190 .. ... 5 May 14, 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 : Arterio ... Sclerosis
Chronic Myo & Endo Cerdetis.
Cordeac Failure.
(OURATION)
........
.. DAY8
Contributory :
(DURATION) ...... . DAY8
(Signed
E V.Scribner Supt.
M.D.
May 14
.190 9 (Address).
Worcester
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
4
years
months.
17
days
Where was disease contracted, If not at place of death ?
Filed
May. 14.
1909
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 cometery.
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
115
Grafton
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
George ... A ..... Spaulding
Registered No.
4.3
Place of )
Grafton Colony, Worcester Insane Asylum
Death * S
Residence
Chelmsford, Mass.
Age
58
.years.
11
13
months.
days
.....
Date of l
Death
S
May .... 14
1909
... .
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
STATISTICAL DETAILS
SEX
mal
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED Widowed
MAIDEN NAME Ť
HUSBAND'S NAME Ť
BIRTHPLACE $ Buscawn N 71.
NAME OF
FATHER
Joseph Jones.
BIRTHPLACE OF FATHER$ Boscawen, 171.
MAIDEN NAME OF MOTHER
BIRTHPLACE
OF MOTHER$
OCCUPATION Retired
INFORMANT §
arthur W. Jours
109 Exeter St. Lawrence Mars
PLACE OF BURIAL OR REMOVAL II
mans Spring Gove Curling UNDERTAKER Walter Perham
DATE OF BURIAL
Juan 1 0 1909
ADDRESS Chelmsford
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
iliness, from.
Ullan 17
190
05 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 Cere bral Safteuro
(DURATION).
100
DAYS
Contributory :
(Signed)
Im Tandall
M.D.
Jung 1905 (Address).
Of well
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
Jime 9
2 derand Doffing
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.
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
116 Chelmsford
RETURN OF A DEATH
(CITY OR DOWN.)
FULL NAME
Warren & gomes.
38
.Registered No.
Place of l
Chelmsford mars
Date of June 8.
1909
Death *
S
Residence
Lawrence Mars
Age
56
.. years.
6
20
.. months.
.days
Death 1
7 190.
(DURATION)
DAYS
1
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
Chelmsford
(CITY OR TOWN.) 39
FULL NAME.
Halen &. Lord
Place of l
Chelmsford
Death *
S
Residence
Chelmsford
Age
21
.. years.
9
8
months
.days
STATISTICAL DETAILS
SEX_ Female
COLOR
White
SINGLE, MARRIED, .
DIVORCED
Sunyle
MAIDEN NAME + HUSBAND'S NAME t
BIRTHPLACE #
Laurence
NAME OF
FATHER
Edwin H. Lord
BIRTHPLACE
OF FATHER#
Springvale, Maine
MAIDEN NAME
OF MOTHER
Etta Strany
BIRTHPLACE
OF MOTHER#
Manchester n.H.
OCCUPATION
Teacher
INFORMANT §
S. C. Perham
PLACE OF BURIAL OR REMOVAL II Bellevue Com.
DATE OF BURIAL
June 15 1909
UNDERTAKER
Mr. Perham
ADDRESS
Chelmsford
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that i attended deceased during last
100
ittiress, 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
Jericide
. (DURATION). DAYS
Contributory :
(DURATION).
.DAYS
(Signed) ..
IV. Meg, MA. Medical Examin
A.D.
June 15 1900 (Address)
160 Mammaek 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 21× 15,
190
9. Eduard ). Rolling
Down
Clerk
* City or town, street and number, If any, If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. # State or country ; also city, town or county, If known.
§ Name and address of person giving statistical detalls. Il 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
.Registered No ..
June 13
.190 7
Death
ء
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
STATISTICAL DETAILS
SEX
COLOR
Thit.
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME + HUSBAND'S NAME t
BIRTHPLACE # North Chelmsford WARS.
NAME OF
FATHER
BIRTHPLACE OF FATHER #
Trelan 1
MAIDEN NAME
OF MOTHER
BIRTHPLACE OF MOTHER #
Lowell Fass.
OCCUPATION
INFORMANT §
Tathor
PLACE OF BURIAL OR REMOVAL II
Lowell fuss.
DATE OF BURIAL
June 15
190 ...
9
St. Patrick's Cemetery
UNDERTAKER
ADDRESS
S. t. ODonnell Non 324 Mauset St
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from .. June 6 1909 to Jamie 14 190 ... 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 :
Tubercules Menugetis
Contributory : .....
(DURATION) .... DAY8
.
(Signed)
7 E Varer
M.D.
Hora1 4 1909 (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 Same 15
190.
9 Edmand & Rotting
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.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
118
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
1:30 Melon
Registered No.
40
Place of l
Death * S
Church St. North Chelasford
Death
Date of ¿
June 74,100
190
Residence
11
.months ... days
Age
... years.
(DURATION).
17
.. DAYS
-
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED 110121
MAIDEN NAME Ť HUSBAND'S NAME t
BIRTHPLACE # Lawrence Mass
NAME OF
FATHER
Michael Z. Dorahu
BIRTHPLACE
OF FATHER#
Fr.lund
MAIDEN NAME
OF MOTHER
-Ilen Haggerty
BIRTHPLACE
OF MOTHER #
Ir land
OCCUPATION Fron Coller
INFORMANT §
Thomas T. Denahue
Con
.
PLACE OF BURIAL OR REMOVAL I
St. Bernard Cemetery
Concord Moos
DATE OF BURIAL
1900
ADDRESS
I.F. Donnell Sous 324 Marketshome
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from
nich.
190.9 .. to June 18 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 : Pernicious anaenua.
One year. (DURATION). DAYS
Contributory :
DURATION)
. DAYS
(Signed).
Amara tward.
M.D.
Om 18 1909 (Address)
Thelunsford Man.
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
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Speclai 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
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Registered No.
11
Piace of )
Date of l
Death *
S
Death
190
Residence
Age
20
years
......
.months .. .days
STATISTICAL DETAILS
SEX
COMMONWEALTH OF MASSACHUSETTS
119
Forall Mass
1
.
MARGIN RESERVED FOR BINDING ALL NAMES TO BE IN FULL
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Sin~1e
MAIDEN NAME + HUSBAND'S NAME t
BIRTHPLACE #
NAME OF
FATHER
BIRTHPLACE
OF FATHER+
MAIDEN NAME
OF MOTHER
Alice Voraba
BIRTHPLACE
OF MOTHER #
OCCUPATION Operatore
INFORMANT §
Sister Fiss Tary refrath
PLACE OF BURIAL OR REMOVAL I
-
DATE OF BURIAL
C ..
190.
UNDERTAKER
ADDRESS
J.J. O Donnell /Jour 324 MarketVx
PHYSICIAN'S CERTIFICATE
¡ HEREBY CERTIFY that I attended deceased during last illness, from. May 19 1909 to Jaume 19 909 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 : Urgencia
about. 30 days. KOURATION ) .. DAYİ
Contributory :
(DURATION) .. DAYS
(Signed)
M.D.
.190 ...... (Address).
H. Chelaufend
SPECIAL INFORMATION only for Hospitals, institutions, Transients, or Recent Residents.
How long at Place of Death ? years ...
... months. .................. days
Where was disease contracted, If not at place of death ?
Filed June 21 1907 Edward J. Rolling
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.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
COMMONWEALTH OF MASSACHUSETTS
120
RETURN OF A DEATH
(CITY OR TOWN.)
412
Registered No.
Date of ¿
-
Death *
5
Death
1
190
Residence
Age
.. years.
months ...
.. days
FULL NAME Place of )
-
STATISTICAL DETAILS
·
1
1
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Charles MS Nicholl
.Registered No ..
Place of l
Mt. Pleasant Sono le helinfare
Death
Residence
.. years.
.. months.
.days
STATISTICAL DETAILS
SEX
Mali
COLOR
white
SINGLE,MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME t
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