USA > Massachusetts > Middlesex County > Chelmsford > Deaths 1910-1911 > Part 5
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culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, F'alls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Carroder
12 MAIDEN NAME OF MOTHER Justice dansk Remoule
13 BIRTHPLACE OF MOTHER (State or country)
Comunicados
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address) Areth Gluhamburg
15 Filed Jamal 15 1910 Edward & Robbing
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED. OR DIVORCED (Write the word)
DATE OF BIRTH
Iran. (Month)
(Day)
7 AGE
48 .yrs. .
mos. 7 ds. ....
or ........ min. ?
8 OCCUPATION (a)' Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
If LESS than | day ....... hrs. that 1 last saw her alive on and that death occurred, on the date stated above, at 120In. The CAUSE OF DEATH* was as follows : Tuberculosis pulmonary
primary of high found
descendants of Lucca ..... inteding Yabout the .(Duration) .... yrs. as. Though I have never alleted hes Contributory que writerin este (SECONDARY) (Dyration) .. yrs. mos. ds.
(Signed)
7 E Varney
M.D.
une/21910 (Address).
Horst Chilean fort
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
In the
ds.
State.
yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence ..
19 PLACE OF BURJAL OR REMOVAL
DATE OF BURIAL Have 15.199
20 UNDERTAKER
ADDRESS
135
A Archambault Auernmark
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD."
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE, OF DEATH Varthe The Sunspallia 75
(No Manis It South Gehusfull
St.
Ward)
210 dr. Che hufand (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
'FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE manic 11 With thehusband
Registered No. 442
PERSONAL AND STATISTICAL PARTICULARS
(Month )
16 DATE OF DEATH
June
12
(Day)
1910
(Year)
1861 (Year)
I HEREBY CERTIFY that I attended deceased from June 1, 1910, to June 12, 1918.
9 BIRTHPLACE
(State or country)
Canada
10 NAME OF
FATHER
Jule: Terablauf
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," "Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm luborer, Laborer - Coal ntine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated 1 thus: Farmer (retired, 6 yrs.). For persons who have no
occupation whatever, write Nonc.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- coma, etc., of .. .. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
-
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last 1 illness, from May 27 190 to que/51990, 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 : Chomatisar
Endocarditis
(DURATION) ..
DAYS
Contributory :
(DURATION).
.. DAYS
(Signed).
Autun 4, Derfina
+ .... M.D.
June 16, 196, (Addres).
Cheline ford, mas
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
Same 17
1900
Edward & Robbing
Clerk
PLACE OF BURIALFOR REMOVAL !!
Chelmsford maso
DATE OF BURIAL
June 17
.. 19010
UNDERTAKER
Walter Fecham
ADDRESS
1
211
RETURN OF A DEATH
Chelmsford. Mary, (CITY OR TOWN.)/ ,52
FULL NAME
Janet Warren Morse
.Registered No ......
Place of 1
Chelmsford. Mars.
Date of ¿
June 15
1990
Residence
Age
61
.. years.
11
.months.
.. days
STATISTICAL DETAILS
SEX
COLOR
W
SINGLE, MARRIED,
WIDOWED, OB
DIVORCED
MAIDEN NAME +
Land W. adams
HUSBAND'S NAME t,
Chas. F. More
BIRTHPLACE #
Platsburg 9. 4.
NAME OF
FATHER
John adams
BIRTHPLACE
OF FATHER#
New York State
MAIDEN NAME
OF MOTHER
S
BIRTHPLACE
OF MOTHER #
OCCUPATION
Herwenige
INFORMANT §
chas. Fr Mouse.
* 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.
COMMONWEALTH OF MASSACHUSETTS
Death *
Death 5
L
WRITE PLAINLY, WITH UNFADING INK- THIS IS A PERMANENT RECORD.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
1.owell
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH will niall (No.
St. :
9
.. Ward)
Elsie Clausen
FULL NAME [If married or divorced woman or widow give maiden name, Also name of bushare @RESIDENCE Cor. Churi
+ Princeton St, no Chelmsford,
Registered No.
474
PERSONAL AND STATISTICAL PARTICULARS
-
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED
OR DIVORCED
(Write the word) Jungle
6 DATE OF BIRTH
may
-
21
0 1904 17
(Month)/
(Day)
(Year)
7 AGE
6
.yrs.
mos.
29 ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
School Sul
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Sweden
.. yrs. ...
) (Duration).
Perforation
mos.
....
Contributory
(SECONDARY)
.(Duration)
yrs.
mos.
ds
(Signed)
1
andrew Cinders
M.O.
June 26 1911 (Address) At Fabri 100226
/* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
yrs.
mos.
ds.
State ....
yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL no. Chelmsford,
DATE OF BURIAL
Irme 2/1916
20 UNDERTAKER
ADDRESS
15 Filed June 21 190
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
-
(Month)
(Das)
(Year)
I HEREBY CERTIFY that I attended deceased from
1916, to Jame /Q, 1910.
If LESS than
I day, .......
hrs.
that/I last saw but alive on
Vinne 10
1910
and that death occurred, on the date stated above, at.
89
m.
The CAUSE OF DEATH* was as follows :
(Ipprendicités
10 NAME OF
FATHER
Ernest Clanson
11 BIRTHPLACE
OF FATHER
(State or country)
Ewiden
12 MAIDEN NAME
OF MOTHER
ada, Hanson
13 BIRTHPLACE
OF MOTHER
(State or country)
Sweden
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
d'aller
(Address)
no Chelansford.
212
(City or town.)
fif death occurred in a hospital or institution, give its NAME instead of street and number.]
MARGIN RESERVED FOR BINDING
important. See instructions on back of certificate.
PARENTS
In the
- ds.
y O'Donnell tions 324 market at,
191C
3 SEX
Female White
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of ocoupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to tinie and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid nse of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia, Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sur- coma, etc., of (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronie valvular heart disease ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing deatlı), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " All- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelmsford
(No.
High
St. :
Ward)
213 Chelmsford. (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No. 54
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Hemale White.
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married.
G DATE OF BIRTH
Dec.
16.
(Month)/
(Day)
1868 17
(Year)
I HEREBY CERTIFY that
attended deceased from
191
.... ,
to
Jan 2, 1910,
that I last saw her alive on
(jan. 2, 19:0.
and that death occurred, on the date stated above, atom.
The CAUSE OF DEATH* was as follows :
To the
East of my Knowledge
Uncarecem (in theway)
Indefinite
(Duration)
.yrs.
mos.
ds.
Contributory ..
(SECONDARY)
(Duration)
yrs.
mos.
ds.
Autumn S. Scolonia
M.D.
(5)gned)
July 2
1910 (Address).
Chelmsford, MANS.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
.. yrs.
.. mos.
ds.
State
yrs.
In the
mos.
ds ..
Where was disease contracted, if not at place of death ?
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
Edson Cemetery.
DATE OF BURIAL
July 5.
1910.
16
Filed ...
July 2 1910 Edward SK bbuy
Concl REGISTRAR BAR
16 DATE OF DEATH
July
2.
(Month)
(Day)
1910.
(Year)
7 AGE 41 yrs. 6 mos.
If LESS than 1 day ......... hrs ..
16
ds.
or ......
.. min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
At Home
(b) General nature of industry,
business, or establishment in
which employed (or employer).
At Home
9 BIRTHPLACE
(State or country)
Glasgow, Scotland
10 NAME OF
FATHER
William Adame.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Scotland.
12 MAIDEN NAME
OF MOTHER
Mary Warling.
13 BIRTHPLACE
OF MOTHER
(State or country)
Scotland.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Arthur B. Nichola.
(Address) Bhelmelord, Mères ??
20 UNDERTAKER
Promotenley.
ADDRESS
79 Branch St.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
Agnes D. Michal
chole
FULL NAME. {If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Chelmsford, Marc.
Janee J. Adams. Arthur . Nichole.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have 110 occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia") ; Lobar pneumonia ; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc , Carcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," "An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," " Convulsions," "Debility " ("Congenital," --- "Senilo,"-etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
-
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
MARGIN RESERVED FOR BINDING FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Stillborn Christianson
Registered No. 771
55
Place of l
Death * S ..
Wilen Lane, West Chelmsford, Mass,
Date of l
Death S ...... 1:7.4 .... 3 ...
......
1910
Residence
Wilson Lane, W. Chelmsford
Age.
... years.
...... months ......
....... days
STATISTICAL DETAILS
SEX
Female
COLOR
White
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE #
West Chelmsford, Mass.
NAME OF
FATHER
Jobn Christianson
BIRTHPLACE OF FATHER# Sweden
MAIDEN NAME
OF MOTHER
Hanna Johnson
BIRTHPLACE
OF MOTHER #
Sweden
OCCUPATION
-----
INFORMANT §
4
John Christianson
PLACE OF BURIAL OR REMOVAL II
Edson Cemetery
UNDERTAKER
Hr J. Saunders
ADDRESS
Toowell Mass .
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last iliness, from .. .19 to family 3 ..... 19/0 , 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 : still bank
C
(DURATION) .. DAYS
Contributory :
C
(DURATION). . DAYS
(Signed)
JE Varney
M.D.
.19/0 (Address) H. Chelandes.
.....
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 Sales 6
19/0
Edward \ Robbing
C
Čierk
* 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.
DATE OF BURIAL
Jul & 6 19 10
214
Chelmsford
11
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH De Charme jord (No
St. :.
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
'FULL NAME Marie Yvonne Comtois alias Silbert
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE the inclinaford.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Female
4 COLOR OR RACE Chiter
5 SINGLE
MARRIED
WIDOWED
OR DIVORCED
(Write the word)
Single
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