The volume, 1900–1903
Town Clerk, Winthrop · from the Internet Archive · 562 pages · 36.1 MB
open the file ↗ · original at the source ↗
Digitized by the Internet Archive
in 2016 with funding from
Boston Public Library
https ://arch i ve .org/detai Is/townofwi nth ropre 1 900wi nt
Cammontaltlj af llfassar|ps*tts.
ro. /
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Husband’s Name, Zrr. y /i
Hwnffe, Married, Widowed or Dirmrrd, /.McMMOZ^r.. Occupation, £\rvWj/lyi/<
* Rp^idpnpp $ If out of town, ) \ rn n yf Iss, T w y S' sf
xiesiaence, j also state fuii^li C^JylAJy'b^ S
Place of Birth, '-(/
* Place of Death, y^J/h > ^/yfn^z
Name of Father, (Q'
m
Birthplace of Father, yy&fyt-.yst J \Zl-rir82
Maiden name of Mother, / //It
Birthplace of Mother, / J/L
Place of Interment, (Give name of Cemetery),.
Signature and
place of business
.189 of Undertaker.
PHYSICIANS CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,!
Disease or Cause of Death, §
Duration of sickness,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence ‘
of
Certifying Physician.
Date of Certificate,
cry
7>
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. * If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
I
\
Commontorallfr of Passatfensstts.
Ko. <L
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Husband’s Name,
Single, Married, Widowed or Divorced, x- / Occupation,
* Residence, SKafe&i 7^> ^ V/ ^ ,
also state fully. )
Place of Birth,
*Place of Death,
Name of Father,
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,
Place of Interment, (Give name of Cemetery)
Dated
on
TTU+u/-,
77 C'y'LotJL' oly
I
7lAJ$C& ^0
oJLay^cTs
Ao£yi^,_
Oi/y w /d
.. Signature and
) y place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, f IjU^Uvw) A,gG,.rrzz.Y .
Place and Date of Death, J died at Bv>WR^V..
Disease or Cause of Death, §
T D.
Duration of sickness,
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,
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. { If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
P
w .2
5h -Z3
P P
o ^
O co
p
-p —
-4-9
c3 P
O Cw
a> a
~ .2
«f ) ■«— 3
o °
r— CO
a
O
03
p
o
a.
p °
rt r^
2 fe
£> 2
-a
a a;
2 ^
T3 o
2 I o
8 ° c
a _r «
2 bD
t? a
<u 'Z
> ’—
a> ™
O ^
£ >»
I §
O 54-1
o
<r ^
Ci
CO c3
i— 1 <L>
O «
o
a.
ci
O
P3
Eh
<u
<X>
CO
00
CO
r;
<4-9
«*-<
;n
o
c3
p
o
q
P
-4->
o
o
mO
<D
bD
+3
o
TS
c3
8
o
OJ
8
o
CO
a>
"3
CO
1j
oo
8
o
o
a
CO
o
>>
O
>>
■4J
TS
*8
t-
O
P
o
o
CO
CO
o
T-H
P
p
a > £ v.
(V
- bD
c5
cp
a
£
.2
a
£
o
a p
S 10
^ o
>>
*5
o E
o
o
s
o
bD
o>
a
ci
S
-a 2
^ o
-p
H
P c3
O
S- CO
2 *
>i QJ
C CO
rt "
g J «
ci
5*_i
° 5
J 1
a O
oj S
2
o
O
ci <D
.a -a
a: £
a 32
o
-w
‘5
a
£
o
o
p
o
-*->
-4-9
c3
3 oj
rt
■4-9
o
« o
bD -32
§ *
t- 9
o .2
o
gg
^ s |
a ^
= £
ci
bD
C
•3 » -S
a a
l*
a
a
'C
■t* «
o «
<£ c c
bD
•n « «
5 .2
« * .. vs
bD
bD
o ,t2
a> £
bD
S- «
ci o
— a
« ci
bD V
C o
ci
as
TC ►>>
o P
5
J £
o ^
^ o
.a ‘*"1
.2 >>
^ a
3 C
g
H .r ^
a> .b:
'O 23
o &
a>
cr
a —
o
CO 03
§ 1i
s s
g 0
o
CG
t?
.2
p
c
4V>
>-
o
-4-J
*5
2
T3
o
o
-p
ffiammonbxeall^ ai Ipassaxfeusetts.
Xo. 3
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
-L OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name, ./^3[lAd£^.I/.... . lj3)J!/} / f CJ...ll.Jl4/L^.. Sex, , Color, %
D:ite of Death, /£ , Age, ^ Tea., JJt. Month, / Day/
Maiden Name, j If m0arrrmv^d°wed i
Husband’s Name,.
Single, Mamed, Widowed -or Divorced, Occupation,
1 1 VofJU^Jh
*Rpsidpnce i If out of town- ! V
xiesiuenoe, j also state fui|y. j
Place of Birth, y0 ^/pl/VV ' ...
* Place of Death, 5 / ilZEcmJjLh. *LGmJ
Name of Father, 03r OiijL^
Birthplace of Father,
Maiden name of Mother^
Birthplace of Mother,
k
Mj?
nAAAJU ® ./ it
(S^hrrra^
Place of Interment, (Give name of Cemetery),
DatecD&t kj IJClfiA AMSAj®. 1 )
/6
%LAMll&sAj.
Signature and t ..^^XAAaa/y.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, f
Place and Date of Death, }
Disease or Cause of Death, §
Duration of sickness,
*1^ Age,jZ.(?....Y /(?.. M C 1).
(fa %(a <_ ij
/O w-C <- ^ <- <- /z \) .
Signature and Residence
of
Certifying Physician.
M. D.
I certify that the above is true to the best of my knowledge and belief.
Date of Certificate,
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
A
1
RETURN OF THE DEATH
cj O
eS
<u 2
fcc •“
5 2
o ^
_ o
o
o> °
£f> J
« «
"o “
.22 qj
rf-> o
O
P- ^3
a
P3
^ °
<D
s
00
a
.2
‘■*3
o
a>
CO
o
o
CO
c
'a
a
a r-i
ra
a
o
>
ti)
c5 ’,3
>>
0
L-
O
a
CO
Cv
CO
<v
"C
CO
0
>
CO
a
rt
c5
pa
CD
a
_<
la
CD
CO
O ^
aa
O
>>
a
c3
c3
a>
O CD g [3
<D
0>
CO
a?
p:
a
o
a
.2
*•+3
o
<D
CO
o
co
a
<D
a
.2
+3
o
<D
CO
CJ
O
CO
c3
cr
a>
ci
M
co
>>
T3
O
.O
a
c3
a
a
p:
<0
<D
CO
>>
cr*
a
a;
a -a
a;
S 5
a> .t:
■s *
o
-a
a
0
c
0
s
0
w>
.a
O
«»-.
0
0
2
S
s
S-4
b£)
'5b
0
&
'S
a
cj
O
QJ
c
a
CO
0
^3
<u
p
a
.2
+3
o
0)
CO
<D
o
CO
a:
O
-+j
oS
o
a:
-*-3
o
fcD
o
a
a
o
o
PJ
*-3
c5
pa
c3 O
®ammonfojea:It(j d llfessarfettsetls.
No. ^~/:
■
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL AUT_WITH INK. ALL NAMES TO BE IN FULL.)
'/. / UIAAISVUC^^ Sex,
Name^Z"'''^^'?' A.AUY AY\LA/.. / IAJ~AYLA/L£YY Sex, / (A-/ Color,
Date of Death, • Age,^ ^ Y ears, (o Months, 7 TT)aV^>--
Maiden Name, j If m^^owed
Husband’s Name, (L
I
4
Single, Married, Widowed ui Divuiccd, ^ Occupation,
* Residence, j iLHtafe K L / ^ , ^Cu^Cpk
Place of Birth, /& C^AA^..
*Place of Death, / 6 v X) L'MUCyiAL <S fajuJ /
Name of Father, ....(2^ l2JaJCXAA^
Birthplace of Father, • YO .X) {Y
Maiden name of Mother, A\f ^
Birthplace of Mother, A^Ly.y ~CCY CC- /Q)
Place of Interment, (Oive name of Cemetery), VAt^jC
{
D ath(t\ at AA.Y. (A 'Jo
1 189
on
Signatur
place of business
of Undertaker.
»„d i .. . __
itul
Name and Age of Deceased,!
Place and Date of Death,!
Disease or Cause of Death, §
PHYSJCIAN’S CERTIFICATE.
AD.. 1 /UA/A/i/lr^j Age, 3.2,.. Y. £ M.f~V D.
<£/ (5 /7 FSW
Duration of sickness,
died at
I certify that the above is true to the best of my knowledge and belief.
^ /\L * /&Z7Z^*0*-
Signature and Residence 1
of
Certifying Physician.
......M, D.
Date of Certificate,
Give also street and number, if any.
t Or sex of Infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
as •-
o a:
a k
O o
«
a>
CO
a
o
Q,
a
Ci
;s 5
•S 6
>■» ^
o 5
<u
to ^
S «
o **
O cj
CC ii
i-. ri
O
C3
O
<U
aJ
Eh
u
•- a
c* rt
a) <m
O
C5 33
00 c5
a
P3
qs ~ 00
O c5 P
w <v> o
o ^ 33
?/) ^ 8
S O CO
-g So O
v-' flj
P5
-«-s
c3
2 ^ ^
3 be
rt
o
CO
CO <D
CJ
;-
H %—
rn
>
~ cj
o
*3
2'' -
V3
5
^ 3p
o
D
4-P
CD ‘3
> 5
cp *!p
CO
CO
CP
G?
D
O
CO
CD
CO
t> «M
o
qB
In
>>
O
rQ
P
c3
a
^ £
c3 <£>
cd
rp a
o
c3 *,3
_ O
CD
pa
~ a
a 5
cd -r-.
a) >
CD ^
O 3
Cm C5
CO
CD r— .X
cd
a>
CO
a rg
-P c;
bo
O
CO ;_ P
c; o
pj o
a ~ -a
■ — a> •—
£
.9
a
£
o
-4->
3
>>
'3
cj
a
o
s
o
bl)
>>
"E
s
o
a
£ 3
~ ci
.- o
a a>
<D To
S <d
33 P
CJ
P3
o
pa
£
, a
3 .2
be o
g be
~ 5
o a
be
<= >
£ a3
^ a
5 P
&1 "a
22 >>
•2 £
* I
>>
a
<o .2
'C a3
O &
<! Ph <1
a
cr
a
*35
o
r;
o
a
s
CD
s
fcD
•H
o
O
a;
E.
CD
CJ
P2
33
CJ
o
o
o
O)
>•
'be
O
s
s
o
<D
C"
durin
t*-.
be
.2
CO
CO
CD
*3
P
rt
■^>
P3
.2
<£m
rt
33
ci
H
o
CJ
c
-^>
CD
CO
rt
o
£
<D
"c3
CJ
CJ
o
CO
CD
r—i
CO
ci
rrt
CJ
3o
P3
G
CO
Ui
CJ
g;
c3
3
3
5
.2
p
4^»
a;
CO
CO
33
*5
ci
.2
!Q
rH
CD
«3
CJ
*-*->
o
CD
P2
£
a>
o
p
cJ
"p
O
O
O
c3
O
*3
o
33
<4M
o
pa
t-4
cj
"3
CD
O
PJ
■*; cs
CD CD
<D P3
.Vo. S'
ffiammottfomltfr of
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name, ...
ILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Sex, Z
olor,
Z3
Date of Death, ^ ; Age, Years, <rY^Months, c V.Days.
Maiden Name ( If married, widowed
Jiaiueii i.>ame, j 0r divorced.
Husband’s Name,
■Siimle, Married, Widowed ui Bit meed, - Occupation, /S
* Residence, j ^“tafe E3£ | / W'o/2 PauM J ^luiS.
Place of Birth,
* Place of Death,
Name of Father,
Birthplace of Father,
Maiden name of Mother,
/ (DaJ^flcusL oL) A
<■ PHYSICIAN’S CERTIFICATE.
Name afkl Age of Deceased,! J ^21/Ul Age
Place and Date of Death,! died at .... /..//GaJSjz-'ud.
Disease or Cause of Death, § ^
..Y/1/..M 1
/ J Vis,
Duration of sickness,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
of
Certifying Physician.
'CZJEJL
Date of Certificate,
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. { If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
M. D.
RETURN OF THE DEATH
o
o
'•*4
o
00
-u
c3
00
rs
v
a
oT .2
u — -
S 3
O -f
2 *-S
O co
3
rt 3 o
o rt
r3 rrt
ej O e3
Si ^
5 2 ^
•* o **
3 _ O
CO C
O —
«*-
> fl o
o o
03
S a
.fl o 2:
^ fl- -=»
<y 03
o
c
a
bo
p
03
03
03
03
03
CO
^ GO
p
rf
fl
O
fl-
V Js
*03 O
2}
03
bD ^3
a S
2 °
■P 22
03 p
03 eS
03 03
03
03
co 2
2>
o
o
03 O
03
r- ^ 03
O rfl >
~ J: ^
^ 5
03 *fl P
> ^ fl
« co «*
O ~
2 >> 3
•- 3 CO
S, rt
w U-i
£ 'S °
t- 23 p
O p rt
CO fl
a
U
O
03
'fl
fl
03
03
03
P
fl
03
P
«*—
fl
fl
.2
^3
5
O
23
p
p
03
03
O
03
pj
03
03
03
a>
«*— i
O 03 P>
£ ^ S
o £
<i! ° rt
03
03 a S?
_ T <^~i
p p fl
03 ^
^ *> «=
5 rt 3
p *2
y g *3
•2 CO fe
§■ £ *
^3 C.
3 O S
.2^2
03 H 03
•r 03 o
2 2 4
p* 03
He* fl
rr; ^ O
03 rw —
03
03
CO
M I
« ®
>>
T3
O
03
a
fl 3
g cr
fl 03
03
'S
fl
o *-
p 03
§ 5
s
03 S
2 *
**■* J-l
03 03
23 22
C g
cr
03
bD
o
0-30
fl
bD
p , ,
fl
03
£
a
o
g
g
o
O
03 g
^ CO
C3 «
03
03
CO
fl
23
fl bD
a
fl O
T3 03 .2
03 23 — rj CC
03 p > w •- -
■i d
o
o
E
o
bD
3
>>
a HL
& £
3 o
y
o o
^_3
.te «
O y
a> To
'C
y
^ qs
-u
o
a cj -r.
S **
3
3 O
rt
O
6C y
V bD
s Sr
rt
5 "g
bD
.2 J
co “
2? '-
•g H ^ fi <5
>>
15
03
c
rt
o
2
£
.2
a
c
c3
"O
ou ^
a o
.2 a
> 03
2 c5
^ a
a -~
o
03 ^
§ "s
£: E
*< 1
03
Cfl
03 .2
^ 23
fl
cr
03
03
23
O
fl 5
£ 13
a a
Cammontolt^ oi IJtes&djnsetts.
No. C, ?
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
LL OUT WITH INK. ALL NAMES TO BE IN FULL.) /V
y/krtJt/
S Color,,
469 ; Age, Yeai's, ^ Months, 4 ..Days.
Name, </ Y"
Date of Death,
Maiden Name, |Ifm^^wea| ^
Husband’s Name,....' N TZm*
Single, Married, Widowed or Divorced,, Occupation,
* Residence, j ifa21st«» f uYiy! i f jjt£{ J [3<2:. JJ 'll
Place of Birth, ‘
*Place of Death, ^jn/~ '/Sa* y /ci Ihi a^j
Name of Father, 54/ 1 .
Birthplace of Father,
Maiden name of
Birthplace of Mother,
Place of Interment , (Give name of Cemetery)
y?
Dated
on
r 'lrU44. : .jbc&Ui, TttLi k (LlgddAaJMsi..
£&. •saarr^
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,! died at i i Yv\. clA*
slSL &wC\JL OAA A
Disease or Cause of Death, §
Duration of sickness,
YW ... Age,.£li....Y. 1 M. 1).
died at ^ ! -ft , Nv\.
J °i CrC
£*>
.C^XL
I certify that the above is true to the best of my knowledge and belief.
/%. VWv — \-0 O-x^A-1*-'
M. D.
Signature anil Residence ‘
Certifying Physician, f
l^crv (j
Date of Cert ideate, ~\^X w ^ .
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. t If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
[Form No. 37.]
7b y
Permit No.
RETURN OF DEATH.
I
Year, / ^ •
Year, / 3 7^ >
Date of dea,tli
Month, Birth
.Month. ■ ^ge i
Bay, / -
Day,
Name in fulf/y
Residence,
Malden name.
Dayt.
Sex
c
Male
' fkmrrir.
Wife of
Conjugal conditio ;/ \
| Si ngilT
Married.
W~bd'f>wed .
.Dii 'vi I ert.
White.
B 1 ack (Net? ru 01 mi. ml)
Color <{ Indium.
Chines*.
Japan o&e>.
Widow of
f Street, | ' ( f)
Place of death > ,, , .
Place of birth,
Occupation .
Name of Falh$rf£N^N/^*z^
Birthplace of Father,
Place of interment,. NdNN' a-zr-sN
nF uu »
Malden Name of MotlmTy^-yn'i^c^^
<k
Q-— Undertaker.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DCATH.
— gaxlrm.' — N&-. / ,j> 190C .
tt — ' Age,
Name and, age of deceased y
*~z> .
Date and, place of death ,* ...e^' /*?
^ Chi ef cause, 7 Idtax t-c Qi<ce^
| Contributing cause... < a_ 6
j Chief cause. 7? ^
Disease
Duration
I
Contributing cause,
Cn, da.
y
I certify that the above is true, to the best of my knowledge and belief.
Name and residence ) Uf/ f l^kfK {lJ M $
of physician, \ ^ > '
/f HJ > V/
... M B.
‘If in an institution, state how long an inmate and previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows : — Saturdays, 9 A.M. till I P.M. except during the months of June
July, August and September, when the office will be closed on Saturdays at 12 M ; Sundays, 10 A M till 12 M Holidays, from 10 A M till 12 M ; other
days, from 9 A.M, till 5 P.M.
y
. . --
Cammonbxealtfe of
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
A) (FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name, ' [ .I S-,/' Sex, J. Color, Xr
Date of Death, I - l.Cf (/V *89- ; Age, 7 ?^. Years, CV — Months,'^— '"...Days.
Maiden Name, j If ™Xdirad?wed j
Husband’s Name, ^
/Tnuli, Mwwi&d, Widowed or Divorced, Occupation,
* Residence, j “ ^ £S£ j
Place of Birth,
* Place of Death,
Name of Father,
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,
JjeJtuJ&S*. £Lin
( \J\aaM^AVv^
/c) KCUs^SjJU
Place of Interment, (Give name of Cemetery),
i me.. k
Dated at
1SSCT
on
Signature and
place of business
of Undertaker.
rr+r
h
PHYSICIAN'S CERTIFICATE.
$ Age, 22. Y.
died at / • /
Name and Age of Deceased, f
Place and Date of Death,}
Disease or Cause of Death, §
Duration of sickness,
M D.
0 fctft
CTy
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence ‘
of
Certifying Physician. ,
Date of Certificate,
. D.
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
return of the death
i
J
i
ffiammonfaxealtfe nf IPassarfrnsetts.
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL ou
rH I N,Kj\ all names to be in FULL.)
fh
Sex, tT4-
Name, .fiOa (2s Os i / 4 ^ /OiXiaL Sex, 17* Color, / ^
Date of Death, ~2lb.aA.eAy. $* ; A £re, . Q Years, ¥■ Months, f? Days
Maiden Name, j If Td^ld?wed I ,
Husband’s Name,
. Shu^Us Married, W i dtrwer^-or - -Dkvoreed^ Occupation,
* Residence, j Estate S^J ' /o CTUaA iQcrCLoO
Place of Birth,
*Place of Death, 22 */g_ ^yVLCKxi^-
£, / C v, f /> A
Name of Father, /xZa
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother, fxdP, 1 ~z:£.
on
iaM
, /Qlrf/s Si-nature and L
//lout./L- y '■ 1 M \
Place of Interment, (Give name of Cemetery),
Dated at
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, f <v Age ^ L. Y . 2 M • ^2
Place and Date of Death, %
Disease or Cause of Death, §
Duration of sickness,
D.
tfjLt ,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence *
of
Certifying Physician. .
Date of Certified', .
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
M. D.
RETURN OF THE DEATH
g;
L
a
o
o
o
c
£
c
o
‘5
<D
o
o
-S3
C3
o
... /6
Cammonbjjeall^ of lltassarfrusetts,
RETURN OF A DEATH.
To the Clerk of the City or Town In which the death occurred.
..Color,
Maiden Name, j If m^fvd^wed |
Husband’s Name, Q
Single, Married, Widowed or Divorced, Occupation, yWaA iaAj Tllm aaajQaj
* Residence, j ' A
Place of Birth,
^-#yyv\s 1^A).CU>A
* Place of Death, c&A} cf/lj>4/i±, (T'y'lsjf
Name of Father, ;^> ^
Birthplace of Father, A)cxhAA^j ^1/Vy.uw. ^
Maiden name of Mother, "TVUoaaj Q^cald.
Birthplace of Mother, JUAj...
Place of Interment, (Give name of Cemetery). Q^a/km. ..m y...
Dated at If ^ Signature and
on TPUdAokj *d * ’%£' 7?^£<l
PHYSICIANS CERTIFICATE.
Name and Age of Deceased, f
Place and Date of Death, $
Disease or Cause of Death, §
Duration of sickness,
Q* w/. $ Age,£? Y (/.M. AAjD.
diec^at /A.
f. - - ...
AsUa-4-'
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,
/if
(7^/044).
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
Commotihiealtfr nf IPassaxl^usctts.
Xo.
//
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name,
f (FILL mjtj1 WITH INK. ALL NAMbS TU ttb IN hULL.I ^
\ Cbiidj 9JJ • Sex, 'if Color, 2k
Date of Death, TJAjcu^&ky // Vtf ; Age,. Years, Osr-- Months, /£. •Day i
Maiden Name, j If “E^&SST"”1 j
Husband’s Name,
Single, Married, Widened or Diymied,.
*Rpsidpnpp ^ ^ ou^ town, i
xiesiueuoe, j also gtate ful)y ]
Place of Birth, 6~ 0, GLjLL
'’Place of Death, y^L CltrtAA^ p
Name of Father, Qt, (2ncluA4r
Birthplace of Father, / .J(' ^ tv: '
r JaIaja. d.j>. 'yiS- , ..]/lA.'C\ Lsiy,v/s&4 -lb
Maiden name of Mother,
Birthplace of Mother, TkA^tL
vrv
Place of Interment, (Give name of Cemetery), gA'-A.fXAA, /jD J>,yidJ>J$A
Dated at Signature and (
on THousAs p^n°Lbreera9 { Qfoltrtzu.
PHYSICIANS CERTIFICATE.
Name and Age of Deceased,! ^ ^ Age, Y. M./S*
Place and Date of Death,! died at Ok 189
Disease or Cause of Death, § j
D.
Duration of sickness,
i cL
I certify that the above is true to tire best of my knowledge and belief.
Date of Certificate
Signature and Residence
of
Certifying Physician.
M. D.
Give also street and number, if any.
t Or sex of infant not named. If still-bora, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
►1
\ \
03
a3 —
c3
o>
ca
c/5
d
o
aa
a
o
aa
03 ^
5 r5 00
C
C3 r-^
.2 rt
£> 3
o a .2
d
tc
o JA
— j
rt
CJ
'C
d o
.3 oj
o
-a
w q; ^ — «
~ •- S3 « 5
33
O
3 «
M “
►» •?>
•a —
3 13
<u
a .-
c3 3
g cr
§ g
«
•&
J a j
“3 31
<3 o
a
o
o
<!
o
-SJ*
CL,
rt
O J3
o
>> 3
a cfl
d
O
aa
ci
03
aJ
o
03
03
03
03
05
>>
a
c5
«*—
O
as
a
03
aa
o
13
a
CO
a
03
CO
03
a?
C/5
T2
a
O^o
S
a3
*s
a
-C
■4-3
03
bD
O
T3
2 ^ s
bD
O <5 <S =•
a
o
O
c
la
a — 1
o>
a bo
3 Q
t- •£
aa
o
<4—
bD
O* 'w S
a *— »
* g 'S
fl3 O 0)
.a
a
a
la
a:
H
<4—1
o
ki
o
a
o
03
s
a.
a
03
H3
03
03
i3 .a
^ a
o £
£
.2
a
o
•4-3
o
*5
03
aa
03
aa
o
03
03
-a
Eh
aa
-4-3
>>
a s
2 .2
a 0
a
o
o
>>
-4-9
*5
03
aa
^ o
bD -?
§ *
, a
5 .2
bD
aa
03
*2
e- CS
03 O ,t2
bC o ^
2 bD
a 03
a
-a
03
bD
.2
'>
ci
aa
a
o
-4-3
*3
03
2 *
S 9
a
c
C3
ca
.9 o
<D 03
aa
4-3
O
a
a1
03
O
aa
-4^
13
03
ca
Permit No.
RETURN OF DEATH
BOSTON.
r.,,JL.c.c ,
Year
Years
■ l
Date of death j Month Qirth | Month , Age | Months, J
y Day, ' Day, U ' Days.
Name in fall, Residence, dju*-,
Maiden name,
^ Male.
Sex
Femrthe.
Conjugal condition {
\JL^
Single*^
Married.
Widowed ^
Divorced. .
Widow of.
cs-Gl
Color
White.
B lack Wegrtt-or mkx'-ed)
Indian, —
Ch-ine.se.
J apanese. ^
t
/
Wife of
Place of death j ^ ee\
Place of birth,
Occupation, r- -o-v->x_
Name of Father, f < Maiden Name of Mother,
Birthplace of Father, ¥ — Birthplace of Mother, a
di... ®ia r~ —t- t? P^^rfrzi.*
Place of interment ,r
..1X3.
Undertaker.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF D-EATH.
Boston, (Lf 190
Name and ' age of deceased ,# t
Date a,nd place of death,* . fvo.
r Sp
Chief cause, L/.N
Contributing cause,
Chief cause,... —
Disease
years.
Duration
1
( Contributing cause,
M.D.
I certify that the above is true, to the best of my knowledge and belief.
Name and residence ) _
of physician, > ^ ¥&■/
♦If in an institution, state how long an inmate and previou^foatdflrii
The office of the Boerd of Health will be open for the granting of permit? for bplnal, as follows : — Saturdays, 9 AM. till I P.M except during the months of June
July, August and September, when the office will be closed on ^a^irdp/s at 12 M ; Sundays, 10 A M till 12 M Holidays, from 10 A M till 12 M ; other
Qj-x <PCZXZi*/)
*
[Form So. 37.]
^>/3
Permit No.
RETURN OF DEATH,
DQ^EOtX.
[ Year,
Year, O
f
Date of death <j Month ,
\firth
Month, /
Age {
l T»V, /f.
Day,
l
Years ,
fjr.
Name in full,'*
Maiden name,
f Mater
Sex
( Female,.
Wife of
Place of death j ^ eel’ [
Place of birth,
Occupation ,
Na,me of Father '
Birthplace of Father;
Place of interment,
c / C-
V
Conjugal condition <!
Single.
Married .
| Widowed .
Dir-orrerhr
Jgfidow of.
While.
Jtfack (Negro or mC\ed)
Color { I rr din rh
J-apaneeo.
(INN;
<tN . Maiden Name of MotheiyA^-jN^f ^ - &>'
Bipijkplace of Mother,
Undertaker.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF D€ATH
years.
Name and age of deceased, lX. Age, SN l)
Date and, place of death,* . / & % /?AC &A. UA+*
( Chief cause, C N
i Contributing cav,se...
| Chief cause,... ^
Disease
Duration
i
Contributing cause.
I certify that the above is true, to the best, of my knowledge and belief.
Nam-e and residence )
of physician , .1
*If in an institution, state how lonj; an inmate and previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows : — Saturdays, 9 A.M. till I P.M. except during the months of June,
July, August and September, when the office will be closed on Saturday* at 12 M ; Sundays. 10 A M. till 12 M Holidays, from 10 A M till 12 M. ; other
days, from 9 A.M. till 5 P.M.
I
— — ~~ u—w»»- >-
- - — — ■ —
. . - '
/'/
dtommonfomll^ of lltessarfrusetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
• L-tfXAMES TO/ BEJ
Sex,
Name, JA. J r / Sex, — • Color,
Date of Death, CJjdsltQ ft'” /Jf, ^ ^ T83. ; Age, *J Years, /"'v Months,
Maiden Namp ( If married, widowed j -- — ^
maiaeu i\ame, ( 0r divorced. i f~ • ' .T*^r: ( ^
Husband’s Name, !!L-.....' ' 1 — — rr^ ^
Singie-, Married, Widowed ui Divuii'ed, Occupation, A? /l. A QjLA.
* Residence, j ifSo“ taw Su?.* | Of ^nJJlAY'jo
Place of Birth, ^J^MAdA C7V^
* Place of Death, /d/li *Q , vy id /<^) (iP _lJ
Name of Father, ^sS) <rAiyiy ' JVbcVl/) (m^o
Birthplace of Father, . ....... * 3^)
Maiden name of Mother, ^/O.Q/UVAr
Birthplace of Mother,
Days.
n
Place of Interment, (Give name of Cemetery),
Dated at
YWI.Jq/1 evx- .
4 rya . -<$?■*/<&
r<yf
on
tygyu^ ***
7
C ( f'
Signature and t CdxtAi'iiA&ri f cL...
place of business ■<
of Undertaker. I
/.CL*LA-
PHYSICIANS CERTIFICATE.
Name and Age of Deceased, f* ^_X/ P2-P.. J.P fL.d.C'.j, ... Age,/7 AV \ M. /3 D.
Place and Date of Death, f died at J/'/.L-l-L* frlAA jf? / W a /oftyvOL ft* i'P
C?M 2 $ mol. ft*- xU C ?/qi SL-mJjSLeu
Disease or Cause of Death, §
Duration of sickness, j ^ ^
I certify that the above is true to the best of my knowledge and belief.
s^4d-6-z*-4-/& °6xn*u
<SZ, TKcAZfcty vSC c
Date of Certificate,
Signature and Residence 1
of
Certifying Physician.
M. D.
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
/
RETURN OF THE DEATH
(Jammoiihiealtfe d lllassaxfrusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL, NAMES TO BE IN FULL.)
fa*. ~
Name,
Date of Death,
Maiden Name, j If TSS'tcd !
/« (FILL OUT WITH INK. ALL, NAMES TO BE IN FULL.)
Sex, IIP Color, Alf~
Age, 7 j Years, Months, 7 (0. Days.
Husband’s Name, ...J. CA7A
Single, Married, Widowed or Divorced Occupation, JjpJ 7^'
* Residence, \ *fs™fcta°tfe \Zy. j _..tf dlkltt.. JjlAl'itJl'ik. v /]'(
Place of Birth, ItIlaiA/ .-. L
* Place of Death, ^ ’ iT ft'!, J. ' \ ' '■
Name of Father, S&A/Mlt.. L Am
Birthplace of Father, °i ym 1A1..3CZ. !• tA... 7k.. it 4. jy,
,. WA .£*<*
ll.7l.7Jk
Maiden name of Mother
Birthplace of Mothe r , sJ/4 < fixA/L* — ... . „
(f • ftj j ft y
Place of Interment, (Give name of Cemetery), 'J.l J...
Dated at I \iopJjt..: 1.17'l.iu Jill
on
Signature and
place of business
of Undertaker.
A.cd2....
yvoapj-
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,!
Disease or Cause of Death, §
Duration of sickness,
Age ,7 ^ Y.(* M. / 6 D.
ied at A
/A^v/tfcc A...
vr know
I certify that the above is true to the best of my knowledge and belief.
_..Q^
Signature and Residence '
of
Certifying Physician.
Date of Certificate,
! It
M. D.
i
Give also street and number, if any.
t Or sex of Infant not named. If still-born, so state. { If child died immediately after birth, so state.
§ If a Soldier or Sailor In the War of the Rebellion, give both Primary and Secondary Cause.
#
RETURN OF THE DEATH
o
o
o
a
o
3
73
a
a
a
o
^2
a
73 ’w
- o
4d
44>
o
a w
*3
a.
Ci rW
o
03
a
o
a
'.§ rt
as
4-9
2
2
<fe4
o
r^J
*-3
03
03
73
o
73
S-i
03
73 O
>> ^
a
a- 03
<44
3
o
_Q
03
03
03 3
3S o
c5 O
QJ 03
oq bO
o
o
■£
a
S Q)
2 ^
03
73
a
O
a
a;
+4
O
<
o
a
a
3
03
3
o
03
03
3
o
4-*
<D
bD
s
2
a>
a
o
73
w'
^3
/^N
*a
.2
•
CO
73
‘a
4-3
3
<4-4
3
ci
a
o
o
03
.2
3
o
4-3
ci
a
03
ci
a:
03
73
03
73
s
03
*3
5-4
03
03
CO
03
03
4J
3
a
a
#o
3
03
o
03
73
2
o
03
03
4-3
%—
ci
o 3 ~
~ 2 bU
K. 3
a ,-T
o 3
-»-3
a
O
* n
2 ~ a
,
^ O ^
2 §
— C 73
a
C71 <*_i
S^Q °
t- -2
O 3 a
co rt r-
< a>
03
ca
a
3
f ,
r-
3
>>
03
<4-4
a
73
71
03
a
a
"a
o
<*-.
**
a
O
73
71
a
*a
o
.2
3
03
4-4
a
03
-a
03
73
a
o
71
73
03
a
.2
3
o
03
73
03
03
73
-*->
03
ci
03
a
ci
S
a
ci
<4-4
o
o
73
43
03
<1
03
03
03
73
03
03
c/:
03
Sh
3
C3
C3
O
03
r— <
&
4-J
a
03
a
cr
iH
4-4
o
4-4
03
6
4-3
<4-4
o
4-4
a
as
73
o
4-4
73
a
03
03
a
.2
3
a
4-T
o
3
03
.2
4-4
'a
03
73
4-4
a
73
a
4-4
a
03
03
73
a
03
a
t-i
a
a
03
■r?
£
03
■44
03
"o
03
O
a
a
bd
r\
03
a
03
>
o
a
a
03
5-.
*5
CT*
durin
bD
a
c n
73
03
4-3
a
a
-t-4
as
03
03
a 50
3 2
ci ci ^
03 ci
T3 a
73
o
^ 2
° 3
ci
a
03
■4J
ci
03
73
03
73
a
.2
]03
i--
O
03
a
H
ci
a
73
73
03
+3
%
a
a
£
o
4-3
o
03
73
73
03
ci
<4-4
o
03
03
E
o
to
<x>
4-3 3
a a
S ’5
03
^ a
03 9
- 73
03
4-4
M
03
O
o
a
a
03
o
03
a
a
4-4
a
o
a
4-4
03
o
a
<4-4
73
03
O
03
03
na
a
>>
a
H
a a
£ a
o §
^ 03
o o
4-3
.tf 03
03 03
® 1°
+1 a
<4-4 S-4
o O
-i: >1
03 ^
73
03
T3
03
2
03
a
\
®gmmontaIi{j of
Xo. / (=>
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name, Cld-Wl/.. Sex, ^ ...Color,
7 " ; Age,. £L Years, V Montlii*-, // Days.
Date of Death,
Maiden Name, | 11 m‘\ri^ed°wed i
Husband’s Name,
m:1^. Married, -Widowed ur Biro reed, Occupation,
•Residence, j £Ka°te 'iz
Place of Birth
> state fumuA
, /jjyyi otaJ ~A /
Place of Death, v
Name of Father, \jtlV
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother, 1/ /aa1vvIA:LLO
Place of Interment, (Give name of Cemetery),
Dated at ? rry , Signature and (
l 'JzJ^y p>ace of bU8iaeas j C~*)Ar ' —rf — « JL^yi a
of U ndertaker. ( ## LIAaMAA.
)nt
9- /VLflAA
on
qmJL ^
cO
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, f
Disease or Cause of Death, §
Duration of sickness,
/
I certify that the above is true to the best of my knowledge and belief.
Give also street and number, if any. •
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary aj^tl Secondary Cause.
return of the death
®ammotthxeaItk of lltassa^xisetts.
*
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name, A^[_^ )d/'t!krll4jU3Ui'0u hAo^cyxv^ Sex, \jt Color,
Date of Death, '/ rfeSttr ; A<re, ■ Y«~. 6' Months,
<Davs.
Maiden Name, \u ma0f^Jc^ \ c 1
Husband’s Name,
Single, Marricdr Widowed or Divorced.
^ f
♦Residence, j Lf8o“ta°tfe & i , >
Place of Birth,
-Occupation-^
i3d7 I^lcL
'<7V\AsC\£~
k>
♦Place of Death,
Name of Father,
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,
Place of Interment, (Give name of Cemetery),
r
Dated at
Od-QM^ -Z'J.l
on ...
^ Signature and
/^7 C/l^y place of business
of Undertaker.
\U^/m£A/.5b
oU...
YIAiaaj--
PHYSICIAN’S CERTIFICATE.
^ Xge,(^X- <S~M. A-X
Name and As:e of Deceased,!
c^,
fc
IS
Place and Date of Death,! died at iQji-XXiX — v.V'« «- tZ *2- ,c 189
Disease or Cause of Death, § (^'.9Sr.
csk>
Duration of sickness, j 1/C4- ^VC£-C^C^.
I certify that the above is true to the best of my knowledge and belief.
<_ £~C’l _ M. D.
'TT.^.'. t-xz^ sLl, J/ye Vo
~t^C_ / cno S " ‘
Signature and Residence 1
of
Certifying Physician. ,
ificate, ...*. Zcl
Date of Certific:
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J: If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
Form C.
ffiammonfomltfe of IJtassaxfrusetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name, ^ i Sex^^^tsC^- Color,
Date of Death, <5~ ./ & d ASy- ; Age, (a. <3 Years, Months, Days.
Maiden Name, | If m^?^r^wed ( £L 72L<^£r£^.
Husband’s Name,
Si agio, Married, Widowed <"• I )i wnyfw) Occupation,
•Residence, j «•“•« £J$: | 3 iT f i*" )¥ ,’ , ^ , .A' ff&katat.
Place of Birth, . (j~7Fl?0. '3/^sA-
* Place of Death, *3 $
Name of Father, ?!^Z. -
Birthplace of Father, O
Maiden name of Mother, ??w ✓a
Birthplace of Mother, Z££z...
Place of Interment, (Give name of Cemetery), 2^Crz
Signature and
place of business
of Undertaker.
HYSJCIANS QERTI FLOAT E.
.V^ Age,^J M. I).
Name and Age of Deceased,
Place and Date of Death, [ died at
Disease or Cause of Death, t
Duration of sickness, \J**
I certify that the above is true to the best of my know
Signature and Residence
of
Certifying Physician.
Date of Certificate,
* Give also street and number, if any.
t Give sex of infant not named. If still-born, so state. If child died immediately after birth, so state.
J If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
s
Commoufomltl] af Ittassatfrtisdls.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name,
(FILL OU^WIT^ INK. ALL NAMES TO BE IN FULL.)
Sex, Color,
Date of Death, ; Age, Years, // Months, Days.
Maiden Name, j If m^41^,0'ved {
Husband’s Name,
tdrrj'hv Married ; Widowed or - 1 livrm-crp Occupation,
V/L- 1
Rpsirlpnop ' ^ town, i sy
xvtbiaence, j als0 state fUu^ l
Place of Birth,
* Place of Death,
Name of Father,
Birthplace of Father,
QtM,
/ d / ‘JMapijs A a ( P /^Tn /
') fsL
^ ^ </l I'ltA.i
(2/qaAjl
Maiden name of Mother,
Birthplace of Mother, 9a / i
Place of Interment, (Give name of Cemetery), P $A ? I- i.
Dated at ^ L 0 J L'tP/Vl/oJ-^ Signature and
C — S - / place of business
Oil l^X-y ^ ^L-<- *-<■. t/ of Undertaker.
Idd&ld^
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,!
Disease or Cause of Death, §
Duration of sickness,
Age/^ Y. M. A D
died at
£&L
I certify that the above is true to the best of my knowledge and belief.
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. | If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
a
w .£
^ -4-3
CD
« *-3
O co
be
5
T
o
a
jn
<4M
■*3
43
0
O
Ut
o
*3
CD
a
Cm
.5
#o
;s
c3
*♦3
15
<4—
c
43
cd
CD
a
0
m
co
>>
O
2
oS
m
o
CD
CO
M
CD
<D
CD
4>
<4-4
o
o
as
•43
O
4-3
(D
‘3
a
3
06
CO
3
-43
r-T
o
O
+3
C5
CD
a
0
<4M
0
as
0
a
0
o £
t-
CD
bO
3
3
S o
CO QJ —
.a
C/D
CD
a
3
O
CD
^3
CD
3
a
CO
CD
>
CO
a
CD
4-3
<4-
-
5
.CD
,—
3
*o
0
0)
C/D
?-•
0
*•3
O
a
0
m
—4
3
-*3>
CO
<p
as
-43
g
5
ns
CD
>
CD
Q ;
Sm
ca
<a
CD
*3
a
be
>>
a
a
%
m
in
CD
TS
O
<*-.
<D
3
+3
a O
<4—
>•
3
15
in rS-
.22
2
o
— O
cd
<d
CO
Sh o
CTi 3
CO a
o CD
co ^
o <4-«
-« O
cd
2 a
a 3S
a
.2
+3
o
<D
CO
CD
CD
CO
CD
CD
a=
Jj <D
a ®
>> ^
CD
a .t
C3 S
E
•4-3 CD
g 5
g -d
3 .12
CD
a3
CD
be
O
a ~
(4
a
0
O
a
CD
F*“
a
0
2
a
fl
CD
’~
ring
43
0
<4—
(See
u.
co
CD
4-3
CD
0
>
‘be
2
0
&
a
bo
.a
43
’sZ
a
rt
zz
ci
flj
0
CD
a
0
4-3
CD
CO
3
15
to,
aa
v
m
>>
a
CD
a3
O
u>
&.
CD
a3
H
-a
ff~! CD
4-3 ^
>
a; ,h 3
«Q fe
2 a
c< -
o
-w
o
‘5
a>
S3
S3 ~~
"<3 .2 ■—
co - .12
co S3 >.
a) •— S'
> es .
o 3;
a
5
tM
o
M
a>
a
a
o
ci
-a
,r? o
a. ci ~
- - £
u
bC w 3S
.2 a
'S -a
a ^
ci <^-.
2 ©
2 ,*
8 <3
a> «
p3 a)
H -a
2
a
CD
a
0
4-3
0
4-3
a
#o
0
CO
+3
a
a
4-3
aa
-^3
CD
CO
CD
0
Te
To
aa
CD
CD
a
S-4
u
£_<
a
0
O
a
<4-.
<4-4
!§
aa
4-3
*3
.2
a
T
"5
^4
be
CD
a
CD
bp
3
-a
o
be
.a
>•
a
aa
a
o
CD
CD
a
a
V
o
cd
cd
a
.2
2a
£
>>
-4-3
*3
m a
.r &h
cr
as
£
►>
4-3
o
a
•a
C5
a
<D
♦3
oS
CD
cc
O
a:
t: a
CD CD
cd a:
Cammontollfe ai lltassaxfrusetls.
2». £l.A
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT '
N F\ULL.)
Name, ^ 'l r^Sex, A/ Color, 9>
Date of Death, If.:! I A : 189 ; Age, * Years, *. 'K- Months, r ^ — Days.
Maiden Name, j If n’^&^d?wed I fV C
Husband’s Name,
Single, -Mu i lied, Widowed or DivrirnM, Occupation,
* Residence, | iKafe fuTi": | 0
Place of Birth, ^1/iA/iA
* Place of Death, ^
Name of Father, ^Ia/iA Caas*^-
Birthplace of Father,
Maiden name of Mother
Name and Age of Deceased,!
Place and Date of Death,! died at
Disease or Cause of Death, §
PHYSICIAN’S CERTIFICATE.
Age,.C\_...Y.C\^ M.CXD.
\JaaA\^aa 189
7 7 (aaxA fi> £i>?h )ah^,(QjcA!/ faiix
Duration of sickness,
I certify that the above is true to the best of my knowledge and belief.
Signature ami Residence '
of
Certifying Physician. ,
M. D.
Date of Certificate,
i iS^sSjsLm-
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. 1 If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
o
ja
£
o
rS
a
O
-a
<u
A
O'
o
03
O
<3
<D
23
Q-.
c3
23
o
•3 l"
« fl
-a o
an
<4—1
o
o
22
<— i
CO
rr-
CD
'o
3
3S
23
00
«
o
O
-4J
cS
a
fcD
CD
o
t>
c 2
<4-4
9 o
o w
bO 23
3 O
CO
a
o
a.
3
a
o
CO
S-.
V
Q-
2
*5
CS
<d
ns
<v
22
a °
CS rw
.2 S
£> 2
22
O- a
<d 32
TS o
2
*5 rH
2d
o
^ 23 O
5 s
•3 ”
>> Jr*
1 -o
<D
a .b
c3 S
2 ^
s «
22
O
nS
<D
>
C2
CD
G
Te
a
o
CO
o
<4-1
a
23*
c3
CO
O)
nd
—
s
CO
3 G
(D
i— rl
<4-1
o
k
CO
a
a
cS
^3
>>
2
c3
<4-4
o
2d
-4-J
C5
^ a
cd
co
cS
<D
ns
CD
23 23
-4->
cS rt
a> o
ns *g
« £
c2
23
-t-3
13
<D
£
a
o
a
ns
a
cn
CD
bD
O
<U H S-i
2d
<4-1
o
«i-=>
M
o
a
a
o
>>
a
ns
cS
2d
be
s
o
o
a> q)
cS
.2
C3
«- 1
-4-3
rt
o
o
■*_3
—
CO
<4-3
a
2d
CO <4-3
o
<D
CO
a
OJ
a
t-
a
o8
<D
ns
CD
a
>g
art
CD
(D
u.
•4-3
CD
2
CD
.a <*—
CO
CO
<D
as
2.
ns
•a
3 bD
4J
a
23
G
<o a
’3
cS
CD
a
w o
a «j
T3 5-
^ CD
as <» •-
£
a
a
fc
o
4^>
h
O
>*
O
<d
2d
CO 2d • —
.-a £
c3
<4-1
o
<D
O
G
o
bJD
2-
QJ
o
o
<4-1
a
&.
ns
o
6=
o
-4-3
s
o
o
a
o
-4-31
-4-3
cS
c3
a
.2
'be
<D
a
<D
be
rt
O
t»<s
o
<4-3
CO
CS
as
cS
o
23
O
43
<4-3
O
23
<4^
CO
^cS
be
*3
CD
O
*3)
CO
a
CD
To
23
CD
d
23
CD
2
CD
CS
<2>
a
23
<4-4
O
2
o
a
3
o
<4-.
J-i
o
a
q
<4— <
’3
2d
<4-1
CO
a
ns
o
©
©
c5
CD
2d
£
<4-3
*3
H CU C3 IS
cd .S
^ 23
O £
CD
22 CD
CH 22
C<
◄
c3
a
CD
s rt
u- p
>4
a q)
cr
a
1-4
a o
<2>
2)
O
22
-4-3
(D
23
dtammoniuealtk 0f
, -
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name and Age of Deceased,!
Place and Date of Death,! died at
Disease or Cause of Death, §
Duration of sickness,
2LL.
<iX^e.. i..c.
I certify that the above is true to the best of my knowledge and belief.
M. D.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
O
O
a? a
jz —
4-3
£2
m .2
•—
o 72
o
« +5
O co
O *X3
•3 l"
<u a
— .9
O S
r— CO
c
o
a.
cT
o
CO
cS CS o
a c3 w
r—
o
o
a?
05
a>
bD
2 5
o
r.
Q
53 A °0
ci
£> 2
— a>
jg 5
^ o
4-3
2
*5 f-T
,n
o
CJ
CO
O
^3
£
O ^
^3
rt 2
,20^2
CO w
>> >>
t: ^
2 ^
Cammontomll^ d
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT W'™ INK. ALL names TO BE IN FULL.)
Name, )Uy Sex, nm/UU Color,
Date of Death, yway. jyg$ ; Age, ...^ssarY’ears, Months, c ^ ..Days.
Maiden Name, jIfm^fc^owed|
Husband’s Name,.
iSing4er~Mtn-ricd-Widow^laiL’ Divorced. -4-)rm|uitimi.
* Residence, j aLo^ufe fully.’ j /^t
Place of Birth, / .S
* Place of Death, ./^ / 0X1^
Name of Father,
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,
v .y,
yitaw A j fiie,
Place of Interment, (Give name of Cemetery), ?
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,!
Disease or Cause of Death, §
Age,
M.
D.
died at 189,
Duration of sickness,
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,
189 .
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
5h
O
Ci
00
« .2
U* 4-3
2 G
O 43
O tc
d3 -2
4-3
d d
O d
G
O
d3
O
d3
d
O
d
O
rO
fcO
3
o — <
c/d
d
<D
03
O
55
O ^d
>> §
C cd
d
C5
CO
O D
O
<
be
P»>
d
o
<D
QQ
-4-3
O
4-3
d
gp
.S
JO
la
£
>
d
*4
o
a
<D
15
4-3
*f-4
o
C*
d
.a
<D
dP
H
d
*G
O £
<d
o
o
ra
d
O
03
d
13
£
o
>>
*o
<D
d3
b£)
a
o
O
<p
CD
D
4-3
C/D
d
CC
QJ
u
*d
o
os
O
C/5
O
CD
5
D
CD
5
>
d
03
d2
.5
"£*
O
3
O3
0
d
d
'O
^3
o
a
0
QQ
4-3
D
o
D
>
<D
CQ
£
>
cd
o
be
>>
*5
>>
P
a
d
CD
C/5
D
03
CD
-33
H
- o
d jzj
D o
03 *G
Z l
d
° 5
.1 1
o I
d 2
o
CD 2
S
o
O
*d o
d3 -G
CD 4-3
'S .3
-a
w b ’3
►>
4-3
o
D
d3
TEL
s
o
o
o
o
.2 o
to -3
s *
. c
o .2
'+- y
-a O
.5 r3
’S3 ~
’? o
>> ,2
^2
o
>>
T3 33
-§ 'a
cr
o
o
o
cn
03
a>
w
cl
_=
r3 -S t3
cr
o
> >
S3
bo
O
S a
cr rs ,g
t* o
O "
cc
be W
s
.2 S3
be 2
« +;
~ o
a %-i
.2 >>
a if
2 si
«« s
.r Cr
cr
a
TS
*4-4
o
<D
bp
3
d3
O
be
n
*P
d
dP
d
o
03
a
d
-a
4-3
£
<D
O
a
d
03
o
o
a
d
4-3
o
>>
G
<5
GP
4-3
O
<D - .
d °
O
Cammontolt^ of
k
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
-Single-, -Married, Widowed Birrm t d,- Occupation,
also state fullv.i •«*'•
. 6V
*Rp<tif1pnrp S If out of town> (
Xiesiuence, , , t t f ,,
Place of Birth,
* Place of Death, ^ ®-CX- 0(.j P (/l/lA^yyy,
' out* L
JA/Ia^
Name of Father,
Birthplace of Father, ^
Maiden name of Mother, s ct/...
Birthplace of Mother, ... C 7 f ■' x
Place of Interment, (Give name of Cemetery),. Q^aJAmdUL yUaAMJL--
&h;i,icJL)
Waal-
Dated at A'
on V.H/C
' d . 7 . ' l O' Signature and
/f v r y 01A, place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,!
Disease or Cause of Death, §
Duration of sickness,
Y. ^ M.«2 p D.
9)Cot^ZZZ<rt/ %<y
died at
/aa/y?
I certify that the above is true to the best of my knowledge and belief.
A; M> D>
Signature and Residence ‘
of
Certifying Physician. ,
Date of Certificate,
c?
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
O
O *G
cs a
05 c5
cS
05
co
6
.G
o
co
o
£
s
o5
0
Gi
05
pG
05
bD
o
o
:n
a
a
CO
a
o
a.
S3
o'
o
_ _ G2
O J §
rn cj 'Z\ty
05
pG
o
t:
G
S3 ~ S?
£ bD
r/ a ^ ^
> 2 3 o
* .2 £ a
tf G2 O
a ^
*G c
2, C3
cr
cu %-<
^ O
o
GO
O 05
co w
-4J
O «*-j
<1 °
o
2 a
Oh
c3
G3
O
05
G3
c3
<G
fl
05
05
CO
>> 3
G co
rt w
^ r,)
g: g:
.a
3
rt
pG
-1-3
3
05
G
O
P
c3
pG
05
4-S
«*—
rt
pG
*£
05
05
CO
05
05
CO
bD
G
a
a s
05 O
G S
^ G3 • —
cs
r-< C3
.G pG
^ co
o E
- 3
h o
05 O
G
O rt
QO «
J- 'w
05
Gu cJ
05
s
o
bD
c3
G
a
o
05
05
-G
H
o
>>
*3
05
pG
•-O G5
CO **->
- O
C3
!§ «
I* 3
G- a
05 G3
3 o
pG -
O K
>>
*C
o
pG
G
c3
a
G
G
cr
^3 5
05
-G
-*-5
05
bD
O
05
05
CO
>>
3
G
bD
G
S 05
~ 3
O .te
3 o
bD G3
05 fe
G
. a
o .2
bD
O ^
bD 05
a
~ 3
O a
bD
G
*?
rt
G3
a
o
t: >>
05
"C GJ
ft
pG £
G- S
.£ >>
a
C0 ^
a cs
; e
< 1
o
05
G
cr
05
o
-4-3
*3
05
05
G
Comnrottbxeallfr 0f IPass&cfrnsetts.
\o.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
/
(FILL OUT^WITH INK. ALL/N^MES TO BE,
Sex , L 1 Color"/?'
Name, 4
Date of Death, /^^Z4V , / '5~" ' ; Age, Years, 0 — Months, .Days.
Maiden Name, jIfm^Swedj
Husband’s Name, C .C — C
Single, Married, Widened Tit DiVullT'd, -Occupation,-
* Residence, j & & j
Place of Birth, i^AAlA^ C.^
* Place of Death, LjAAl-Je (£*aJQ
Name of Father, to oLa/c^oL Q, J(jtAAy/^^\y
Birthplace of Father,
Maiden name of Mother,
. (L‘ %iaL
Birthplace of Mother,
Place of Interment, (Give name of Cemetery),
Dated at
on
QYrft^
/JPu
■y
PHYSICIAN’S CERTIFICATE.
Name and Aee of Deceased,! Age, Y. M. D.
Place and Date of Death,! died at 189
Disease or Cause of Death, § -
Duration of sickness,
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, 189
Give also street and number, if any.
f Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
o
Cl
oc
a
oc
^3
.v„. Qh.
©ommontomlt^ of litassac^usetls.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
'Tl'V Color, 9^
MLL NAMES TO BE IN FULL.)
Sex,
j £fill OUT W,TH
Name,^/CP C^J.
Date of De^h, 7/l/CoUJ J " ; Age , ea rs ,C\_ Months 3 Days.
Maiden Name,
Husband’s Name,
Single, Married, Widowed or Divorced,
*T?pqi/-lpr»/-»p ^ If OUt Of tOWIl, i
nesiaence, j alg0 6tate ful]y
Place of Birth,
Occupation,
&41siaaaJL>
f Place of Death, Sj} iJ&vuJLeAsk CJ^tviAAX
Name of Father, ^ /
•x
Birthplace of Father, .
-= . ' -
*
Maiden name of Mother,
Birthplace of Mother,
Place of Interment, (Give name of Cemetery),
JJ UsVL±SlAJUV / eL
m
Signature and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, f
Place and Date of Death, |
Disease or Cause of Death, §
Duration of sickness,
I certify that the above is true to the best of my knowledge and belie
Signature and Residence '
of
Certifying Physician. ,
Date of Certificate,
189
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
Camittontaltk of $pass&cfrmtls*
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. /ALL NAMES TO BE IN FULL.)
Name , /A/UOAJU Sex, . c? ...Color, O'b
Date of Death, - y ; Age, 3 Years, 3. Months, / Days.
Maiden Name, | If moT^id0wed I
Husband’s Name,....
Single, Married, Widowed or Divorced, ^..-C. Occupation, /" Y
'
^Rpsiflonop ^ ^ out of town, /
xiesiueme, j al80 statejaniy J CZZ...L Vr
Place of Birth, Ol iyf32/lA22&~'/
* Place of Death, 2. 3 /> < 7 ? 1 flA/i/ Odlyl IJl2
Name of Father,....,, . C^2 2^2 r
Birthplace of Father, <n^££AL/.Ji^s <3dy/(-^0,-/^-
Maiden name of Mother, CL) (A/LCL Of , (C^Cl^/UL^ 'i/UA.d* Y
Birthplace of Mother, 2
Place of Interment, (Give name of Cemetery),
* do.
Dated-
\ uuisiSs / 2)''/youvm-
on
Signature and ( J
place of business -<
of Undertaker. (
<td) lAAsyi/iAJ/r cAj
PHYSICIANS CERTIFICATE.
Name and Age of Deceased, f
Place and Date of Death, l
Disease or Cause of Death, §
^^AaL. Age, 3 Y. 3 M.
died at ^rW 3'3/'2 5^ Loi^^ ^UAAJL </ "
<7 [/hu^v^ry^ V|
/ Lr D.
/Q cru .
b rry^rdftc
Duration of sickness,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence '
of
Certifying Ehysician. i
M. D.
Date of Certificate,
<
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. { If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEAlH
o
o Si
Si —
a
o
o
<D
CD
O
<D
CO
CD **-•
- o
3 p—
s §
J, 2
o
o T3
O
O 2 J~
2
ci
CD
-*-3
00
*3
CD
‘3
r-T
O
aa
O
■«->
ci
0
a
0
U-i
O
•o
0
a
#o
<D
O
bD
ci
'C
0
*-3
0
CD
CD
aa
+■?
ci
a
"3
To
0
CD
CD
0
2
3
<D
CD
ar>
«*—
CD
0
CO
CD
O
0
T3
aj
fli
2 *a .2
rS *
~ cd
a .£:
S3 3
o
<*—
ci
aa
2
o
bb
a
2
o ^
>> §
a cd
c3
O
-a
ci
rs
0
>>
CD
<*-t
CD
a
CD
CD
T3
to
«*—
>
ci
0
CD
To
a
*a
to
V*_9
Z->
ci
CO
CD
CD
O
CD
rr>
<D
[3
a
#o
CD
a
o
cd
CD
<1?
<D
CO
a .a
a a
a cr
a a
cd as
a ^
o
CD
-*->
O
<5
0 5
5 rt
a,
ci
?>>
a
*c
<d
>
ca
a
2
CD
CO
ci
<d
T2
bD
O
CD
a:
a3 J3
bD
a
CO
cj a .a
bD
g
o
O
cd
a3
& -c
5 ^ -S 5
^ CD „C • —
bD
a
i- ^
'= Ci o
eJ g
O
-u
.a
H
2
o
cn t,
„ O
2 ►,
I 'S
O QJ
<d
aa
a
bD w p=5
a <d
a
<4-4
s 0
■P O
CD -3
<u fc
a
. a
o .2
CD
« 5
„ 7S ®
■+J
zj u-i si
« © *3
bD o
a; bD
a £
CS
o o
.2
bD
a
’>
ci
aa
a
o
CD
O
a
ci
;-«
O
o
o
ci
05
aa
o
£
a
a
£
c
O
>>
-4^>
*3
cd ^
CD
-a
H
p*“>
aa
a*
^
cd
&
>> Q) rt
£ a- a
ci ^ c
" 5 «
o
cc
aa
o
ci
a>
a:
CammoitfaxealtJj of lllassarfoixsetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH-
ALL\ NAM ES TO BE IN FULL.)
Name, !s *^1 (A*'. Sex, ... Color,
Date of Death, 7 LdAAJL).../.. . ; Age, Years, .Months, -^Days.
Maiden Name, j If m0arnKld?wed i
Husband’s Name,
Single, Married, Widowed or I ) ivorced, >at ion .
^Residence, \ “«** 2lt / e? EZ3L
Place of Birth, /\jJLc^VLJC^J..
* I dace of Death, "fy/t / ^ ff( i ft ^2
Name of Father, /(A
Birthplace of Father,
, /
^cu^p. (z
QyftjJ- id. lAsC-t ■
Maiden name of Mother, (l/UiSdlA
Birthplace of Mother,
Place of Interment, (Give name of Cemetery), (Qs
<&
L/l/lAsi/lsl O'
Signature and
t _ place of business
f 0 r / of Undertaker.
Od^-
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! .. (j.£ 'lAi-t/i' Age,.«?..^L Y.
Place and Date of Death,!
Disease or Cause of Death, §
Duration of sickness,
C^M.C^D.
died at '2lA... t . S U uJ.pJ (AM.iL/o f*<) /£? (fl)
J-/h 'Aidtl/M
Qm<c
I certify that the above is true to the best of my knowledge and belief.
c JiOtrrayC^ /
°f ] /
Certifying Physician. / v
0 n f?d0
Date of Certificate, JC L4/I/LC / /. 189
Give also street and number, if any. W
t Or sex of infant not named. If still-born, so state. J If child .died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
A'
Cammontallk of
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name,
Sex, Color, CHl _
Date of Death / / " J.Q °1' ; Age, ^ / Years, Months, A,/ Days.
Maiden Name, jIfm»f^r^wedj
Husband’s Name,
Married, Widowed" or ~Hivon cd, Occrrpation,
* Residence, '
Place of Birth, & TriA^JL.. ...
* Place of Death, ^ CulU ~^$CyiX/v[ .
Name of Father, jJl'jbJ ' CUl. <- C>/ m > •
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,
t
// l C l L A/ aM.£AA1 i
Place of Interment , (Give name of Cemetery
r),_Q ti
Cl ( (AlsiJ /a<
j&L
Signature and
ruaar j ^
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,!
Disease or Cause of Death, §
tLsT. k<a ...:. , AAg e%.l Y.k. M. ^
0
died at
£~<-'(rVv-v. 0y{. (/X A ' v vft °*f ut cJAAj'
s
Duration of sickness,
I certify that the above is truV to the best of myJknow ledge and belief.
Signature and Residence
of
Certifying Ph/Stcian.
Date of Certificate,
Give also street and number, if any.
t Or sex of Infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the IVar of the Rebellion, give both Primary and Secondary' Cause.
RETURN OF THE DEATH
g
c/T .2
S-H -4-3
G p
o ^
§ ■■§
.a *S
G
05
"D
G
05
09
o
2
<15
05
G3
4-3
G
a
o
g,
5
G
O
a o
>> ^
G- C5
o; 2
05
bfl
05
g
o
2
05
05
05
05
05
m
jo
o
G
G3
03
>>
'G
O
JO
05 r;
^ a.
S c
12
o
r-G
O
G3
>■>
3
*>
05
O ~
2 tu
3
G
o
G
_JZZ
05
05
05
05
t-H
G
4-3
05
G
05
>
J-.
G
•4-3
<4—
G
G
.2
g
5
.2
*2
C
’-2
*Z3
o
05
>■
G
O
05
05
2
-4-3
05
<2
05
>
<G
JO
-4-3
g
05
05
05
05
05
G
<4-1
o
s co
>>
a
G
* 1 1
O
>>
.2
12
*2
a
G
03
05
05
G3
-4-3
43>
c
<4-1
CO
G
05
<4-4
o
<4-4
O
o
2
O0
05
-4-J
05
4-3
G
C5
-4-3*
G
rG
.2
05
00
G
05
*G
05
*2
et
<4-1
o
05
05
T3
2
05
05
G
05
a
o
a
05
-4— >
&4
o
a
4J
05
C
<4-1
o
05
4-3
<4-4
G
GS
G
'5b
o
O
a ^
05
s 5f>
<D G
G *2
a" 'G
G
CJ1
05
05
CO
bD
>>
JO
G 05
^ fcH
3 So 2
O 05
b ~ g
03
G G w
.G r 05
'S 3 ^
G3
.2
12
£
o
>>
4-3
*3
05
JO
g
05
JO
Cammottiueadlk d lllassax^irsetls.
No.
3> a
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. AL£T\NAMES TO BE IN FULL.)
S.CI..U. cJUaj. 22dJO£z (:.JULg..n^J Sex, 'ktU Color, Ob
; Age,
Years, V Months,
Name, ...
Date of Death LAaaJL / V ^JOb. mt
Afoirlpn V <11110 j If married, widowed
iViaiueu ItdLUtJ, j 0r divorced.
Husband’s Name,
-Single, Married, Widowed or- Divorced, Occupation, 7o> ClAL^..QJUULA
* Residence, bS OZ'L.t f ^
Place of Birth, JS. cQqaqia y\, ci
s/ \9 / 7£i4. <°J\ QaACUA-' s&GhJ AA9 c i if it
Days.
*Place of Death,
Name of Father, Qa ti\A. 0 rU cL.
/£) GAt&CbA. cL
79b
\(bblA:QAAcl
IA 0 /o
t
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,
Place of Interment, (Give name of Cemetery)
A / l A / , ^QlAdA
on
Dated ^ 1/ CSM^'IAJ. ( >
Iauiaju. /9l". / y*1
Signature and
place of business
of Undertaker.
t up
Uaasi QAI/tjoIa
csbzfc. A
PHYSICIAN’S CERTIFICATE.
Co*\ dL, (l C ...Ase,lA....Y. /
Name and Age of Deceased,! u
Place and Date of Death,! died at
Disease or Cause of Death, § (TY^A-bl
lS**y*y
Duration of sickness,
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,
MriAtyA
/ 5"~
* i$.'K)
1 J
Give also street and number, if any.
f Or sex of infant not named. If still-bora, so state. J If child died Immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primal1! and Secondary Cause.
return of the death
v„. t.L
®ammonhxeaItfc[ of litosaxiptsetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL,£>UT WIThiONK. ALL NAMES TO BE IN FULL.)
x, ?H
Name, *7 } a)
Date of Death,
Maiden Name, | If ,3«'ved
Sex,
Color,
4LJ. ''Z^cOl&z ; Age, <3%^ Fears, O Months, C~\^_I)a,ys.
Place of Interment, (Give name of Cemetery),.
Dated ^t
on
Signature and
place of business
of Undertaker.
PHYSICIANS CERTIFICATE.
Name and Age of Deceased,!
Disease or Cause of Death, §
Duration of sickness,
^C.o.0
I certify that the above is true to the best of my knowledge and belief.
c-JEZ
Signature and Residence 1
of
Certifying Physician. ,
Date of Certificate,
i
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
No.
I
return of the death
*
Permit No.
[Korin No. 37.]
lyO
\
RETURN OF DEATH.
^BOSTON:
j" Year, y/ ff' PP
Date of death j Month,
Bay, .
Name in full,
Maiden name,
Year. /ZYP j Years, 5X
Birth , Month, <fP~ fZ'C-' • i-gO ) Mnn.th.s ^
1 D(iy> y b
" Besiden ce,
] Months,
Days, ^
Sex -
(.MclIr,.
Female.
f Single.
] Married.
Coniugai condition ; Tr/,. ,
I 1 1/ / ft
White.
Blade (Negro or ruined).
ife of
Widowed.
I Binoreed-r-
Widow of
Color I JbedWeu,
I Chinese.
I Japanese.
^7^ s ,
Place of birth , :::ix ^ dhC
Occupation ,
Na,me of FaiheC, ..
Birthplace of Father^
Place of interment.
Maiden Name
•«. //
of Motherfif^p^f^^
thplace of MotheiyM^p^
Undertaker.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
CL^ ^6 ' 190
Name and age of deceasedN^^^^c^^ <Z1 M . STge
Dai" and, place of death,*
j Chief cause,...
) Contributing cause
^ Chief cause ...
Disease
years.
Duration
Contributing cause.
-lA.
o
♦
I certify that the above is true, to the best of my knowledge and belief.
Name and residence )
of physician, j
‘If In an institution, state how Ion ff an inmate and previous residence.
STB.
The office of the Board of Health will be open for the grant’ng of permits for burial, as follows: — Saturdays, 9 A M. till I P.M , except during the months of June,
July, August and September, when the office will ba closed on Saturdays at 12 M.; Sundays, 10 A.M. till 12 M. ; Holidays, from 10 A M. till 12 M. ; other
days, from 9 A.M till 5 P.M.
... -
I
I
I ~t%" r ■ ™
— «
■;
.
33
Permit No.
RETURN OF DEATH,
BOSTON.
f Year, /
[ v
J ear.
Tears,
Month .
Birth
Month.
Age <
Months,. . / 0.
1 Day, TL L
Day.
f
Days. (c. .. .
Name in fall,
Maiden name.
PJf/ Q[ /
: - .
r&VXC/j
J&MglA*0
Married;
Widowed .
Divorced.
Pesidence,
4jr
*
White.
Black (Negro or mixed).
Indian.
Chinese.
Japanese .
'•""v
r Male
Sex Conjugal condition <( fff.i , Color <
< Female.
D J d I
Wife of... \yJgjph/r\ Widow of.
Place of death \ ’){' eetj j ^ <-'■
Place of birth , ) ,
Occupation .
Name of Father, — Maiden Name of Mother,
Pi rth place of Father, ..&>.< / Birthplace of Mother,
Place of interment, yXry , JL/fa£jN«*&
^ /X> ,ZZ j L
\..MN.x
td Undertaker
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF D€ATH.
Boston, ffVckNg / 190 0 .
Name and age of deceased ,
Pate and, place of death,* .
] Chief cause,
P/) J
j Contributing cause,.,
j Chief cause. ..
( Contributing cause,.
Disease
Duration
?
v <*. c j'
Age, f ^years.
Cy 6
/ Cfyccf/V l 1-^1- T
ait
I certifi/ that the above is true, to the best of my knowledge ajuf belief.
NT
Name and residence )
of physician, J
*If in an institution, state how long an inmate and previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows : — Saturdays, 9 A.M. till I P.M. exce^ during the months of June
July, August and September, when the office will be closed on Saturdays at 12 M ; Sundays, 10 A.M. till 12 M. ; Holidays, from 10 A.M till 12 M ; other
days, from 9 A.M. till 5 P.M.
MT).
N IN
3 1
(lammoniuealik d JSassadpsetls.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FIL
Name, T
Date of Death, /.
Maiden Name, p
Husband’s Name,
yh
Jc&f ; Age,t^° Y ears, — 'Months, f'^wDays.
■£&.. Sex,
..Color,
/dowed
\ or divorced.
iMwgfle, Married, Widowed m* Divorecd,
* T? pqj fl pr» \ If Ollt Of tOWll, /
xvesiueuoe, ( also state fUiiy. $
Place of Birth,
*Place of Death, $(°
Name of Father,
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,
Occupation,
Cy/Wcu^
C* ^COMJ '
(
Place of Interment, (Give name of Cemetery),
Dated ^it
Q/.u..L.La yuk) l/cyyux^ /ca
J& OCU^Aasi’' ^
C
on
y vY.j$ jr
Signature and
place of business
of Undertaker.
uyvi/yi£yy
M.
D.
PHYSICIANS CERTIFICATE.
Name and Age of Deceased,! ^ 0"WlA> ^[£9197' ■//^0 0 1 C-7 7 Hv Cb.. Age,JT^»...Y.
Place and Date of Death,! died at <2, ^ LC&'lAAAy & ^ J
Duration of sickness,
Disease or Cause of Death, §
I certify that the above is true to the best of*my knowledge and belief.
inr -t-**?
Signature and Residence
of
Certifying Physician.
M. D.
Date of Certificate
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
yy 9 yy
RETURN OF THE DEATH
03
*4
a>
G
u.
03
,£3
03
0!)
03
<13
—
03
G
49)
03
G
03
2
Ih
G
2
■*9
G
4-9
—
G
O
G
o
G
G
G
O
G
03
S-»
4-9
C/3
G3
>
g
G
2
03
Gu
S-
<G
G
G
a
*bJJ
>>
03
O
«4_
G
.2
G
G
G
C/3
03
a»
G
*>>
G •
G <0
<*—
>>•
G
G
G
G
G
**-*
O
-G
4^
G
a>
G
G
O g
o
<1
o
— r
a.
G
< 13
r&
H
Cu
a?
C£
G c2
G
> ^
<G
.2 t
G
rG
o e
2
o
a
o
o
o
G
4-9
G
a
G
G
G
.2
2
£
bD
G
G
03
03
CZ3
G <a
03 o
2 ^
G -4-3
G
O
>>
03 ^
2 2
&
G
o>
£
G
O
S
g
o
o £
03 q;
G
CT
bD
a
g c ^
o)
0)
c/2
bD
P"
G
£
G
2-
G
03
G
03
03
o
03
<*-i
O
£
O
4-j
S
o
o
G
03
4->
49
G
G
G
.2
2d
03
G
03
O
o
o
03
G
G
fa
E
o
>>
-4-*
4->
•4-3
o
G
G
03
o
2
to
*5
03
o
2d
03
03
2d
-G
03
G
%—
G
+9
03
a
£
03
G
s
g
o
u-i
o
l~<
o
<4-
>>
G
G
’3
"53
O
<♦-4
rG
03
J-t
o
>>
03
03
4-3
p^>
*5
4-9
<13
2
2
2
3
2
fl
G
03
«*-4
03
H
+9
w
-4-3
Ph
G
cr
G-
03
03
G
G
o
+9
G
2
G
■P
G
O
G
O
2
o
03
03
2
>>
>>
G
O
X}
'B
G
■—
G
S
g
03
G
U
G
03
4->
03
G
O
«4-t
4J
03
G
03
4-9
2
*a
4-9
03
4-9
a
03
03
G3
■a
4-9
49>
O
4-9
03
bD
O
>>
4-9
—
G
G
.2
*2
G
u->
2
4-9
/->
03
03
03
G
4-9
a
G
G
,
r-
G
o
03
03
c
G
O
Ct—
*4-9
03
03
03
G
03
«*-*
rj
o
4-9
03
bD
03
G
a
-a
a
o
G
bD
G
.2
3
o
>
03
G
G
G
G
O
03
03
3
G
g
>9
a
03
<1
4-9
G
0^
CG
*4-9
^4
03
0^
.2
2
£
o
>>
*3
03
o
G
[U35
Permit No.
RETURN OF DEATH.
x V ^ V ‘
'<
f Year, / tfO 0
Year,
| MontlnU^f*-*
Birth
Month, Age
l Day. // J
,
Day ^
Month g,..,.
Days.
CT
Name in fall,
Maiclen name,
Residence,
Sex
Female.
Conjuga l condition
T-Biugte-
' Mamed 7
Widowed.
1 -Dii'vreeJ. —
Color <
White.
$tack "(./\ egro or- mixed,).
(Fh inone-
J_qj)(V) rnr-
^ . Widow ofgfl^f' “SPam
gf JftvN- yTF^ MFx
m'fd-o/ —
Place of dea th j eet’ r
Place of birth ,
Occupation,
Name of Father, c/(f /$£&*<' Maiden Name of Mother, /fine.
Birthplace of Father, — *C Birthplace of Mother, <N
Place of interment,.. /e^~ t .
(b/urf ^ J L gNFPc
Undertaker.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF D€ATH.
IN
Boston^
Name and age of deceased ,
Pate and place of death,*.. fgf /?^z>
r., V/
i Chief cause,
Contributing cause,..
Age, y AL years.
Disease
Duration
j Chief cause...
\
Contributing cause,
I certify that the above is true, to the best of my knowledge and belief.
/s(S fol 4
WD.
Maine and residence )
of physician, •' J
*If in an institution, state how long an inmate ami previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows : — Saturdays, 9 AM. till I P.M. except during the months of June
July, August and September, when the office will be closed on Saturdays at 12 M ; Sundays, 10 A.M. till 12 M, ; Holidays, from 10 A M till 12 M , other
days, from 9 A.M. till 5 P.M,
V
t
-
Form C.
®0mmoniximltl2 nf IJIassidjmsetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name,
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Sex, /&L -Color,
'f/QoV
Date of Death, (../ ' . ./v. ' pfitT ; Age,. y'.y .. Years, v Months, ,£Z ' Days.
Maiden Name, | “-^.^owed |
Husband’s Name,—..
-r-r-
Single, Married, Widowed or -Divorced, Occupation, f _ .
•Residence, ) fun".’ j OoL Sh, \ / • Y
Place of Birth,
•Place of Death, OLsi/
Name and Birthplace of Father,-./ '(JlAtG M A'-
Maiden Name and Birthplace of Mother, QjOi^lG JLs.
^ ^k,cuuk- -zsioJUk/dAM. Gt-b/'
r
Place of Interment, (Give name of Cemetery),.
a K
Signature and
place of business
.190 0 of Undertaker.
Q bi
oU...
2... hill... /£ L
- - ■■ w _ —
/
PHYSICIANS CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,! Vfied at
Disease or Cause of Death, §
Duration of sickness,
A..:. Age, Y. M.
/& T&
D.
M. D.
.0 CsTrisrsfXs ,v,
I certify that the above is true to the best of my knowledge and belief.
It"' ( G/vGv?'
Signature and Residence V ^
Certifying Physician. / ~2~ / dPf '
Date of Certificate, /y/-:
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
)
O
Ci
op
"8
Q
-2
s
C5
co
fe.
o
CO
H
CP
<
■Tf
CS
S=J
H
CU
◄
K
O
H
CP
◄
as
h
X
K
CP
u-
jd
CP
^3
CP
4-3
~a
S-4
<4—
C3
c3
0?
4-3
O
O
CP
to
CP
-*3)
CP
2
c3
■4-S
be
u
CP
ra
o
^3
CP
a *
la .2
43
* §
_r o
-a fc
rt
a
'C
e!
as
a
a
-a
S3
a>
TJ
D
O
-a
o
ai
£
.a
&
a —
-*-> S3
‘■S 2
co a)
a
a
a ,—
a
o o
a ^
bD O
W CJ
u.
CD
2
o
CP
r* CP
Sx
b a
55
O
H
CP
W
m
o
b
c3
««-<
O
aa
-4-3
ci
CP
•C
be
+3
cS
cp
"C
c3
*a
CP
co
<*—
O
cp
c3
.2
2
a
c3
O
.a
43
d
cp
a
OP
"C
CP
c3
M
*£
^3
T5
a
rt
j a
.2
2
£
c3
o CP
2 £
•*e a
2 °
a a
o g
> o
'be o
cp
2 5
CP
a
'C
a
o
CO
£ • r
a
£
o
*a
£
>3
CP >>
CP +2
s ^
° o
be 5
a
<*-.
a °
a M
a Ji
I -2
§ °
CP CP
o
£
o
be
a
cS
O
ca
a o
,a cs
_ 2
o *CP
*“* *co
>> b
4-3 ^d
04
.5 3
OS
+3 rx
XP rH
O
.a *4^
c3
a:
CO
>%
O
>>
a
'bb a 'S
be a
a 's
.2 2
3
cr
CP
CP
c5
^3
a
CP
CP
^a
CP
<4—4
Ph
43
o
t-4
o
+3
43
CP
be
cS
CP
C3
>>
o
4-3
CP
-a
J 3 .2
M O ,Q
a «*-i S
c3
£
CP
CP
CP
c3 „ O
•a •- *
.§ a a
— « '—> CP
cp a
- 2 «
- aa
§ 1
2 1
>1 S3
t; -a
S3 -*-'
« X-
a ©
CO
be S3
a o
!i S3
. ns
a
a:
o
be
a
a
aa
.2 «
•a ® C3 a
S3 -<
Ph
s ^
a
e. «
!>> «
a J
a
cj1
o
H
4.3
*”5
CP
55
o
H
o
H
3X
« 2
2 P
b
s
<4
o
H
CP
*a
CP
CP
ca o
CP
. U2
w
a a
a
UP
'S “
<4—4
o
C/2
C/2
„ CO
o
CP
CZ)
a
aa
a t_i
S o
5 a
a
_co -a
a u*
a o
r3 !-
c3
O
aa
a
a.
>3
aa
a
a3
ci
00
H
O
co
O
o fc
o
5
CP CP
-a -a
CP GO
>• c3
cS ^3
- &
cj a
“ >i
•— ao
o
a
aa
a w
a: O
u " a= .t;
a o
cr1
*5 S3
• — S-t
a
S 2
S5
o
H
O
a
co
a ra as
.2 r'
O
5 'a
E ** -w
u
c
a
H
X
W
I l to
c3
CP
aa .-2
io u
O
i |
as rt
a c-
a o
CP
CP
s °
s a4
r1 ‘-i
a iJ
a a
'C a
a a:
a ^
a <-»
a
p a
a 3
t; a
a co
® a
— -, as
• a
a: a
a
be
F « 2
o
a
co be
a
a a
;§ o
GO rrt
S
ci
04 O
rdP
C3
CP
-a ^3
*73 cl
CP CP
^ ffl
#C0 HH
a <4-«
2 o
o3
O
M
be
a
as
a
a
Pi
8
O
H
a
a
72
be
a
UNDERTAKER S RETURN OF A DEATH
5M-i-'oo.
7uJ7
No. of Record.
County of Middlesex.
City of Cambridge.
Commonwealth) of
llftassacbusetts
No. of Burial Permit.
Name, in full
NO INCOMPLETE RETURN WILL BE ACCEPTED.
Name of Husband,
y, N;
2. Color:
White.
BmWI^Negro or mixed).
3. Sex:
Male.
Fswmtk.
(If widowed, married, or divorced.)
4. Conjugal Condition:
Single.
M I IITIWI).
Widowed.
DrVO»CCI>.
jAKjLNESOi.
5. Date of Death J Month,
( Day, t
8. Occupation,
NOTE. — For Questions 2, 3, and 4, strike out words not applicable.
Year, / 0~0 ( Year, J9 ' f Years,
, 7- Supposed Age -( Months, J
6. Date of Birth if obtainable < Month,
l Day, tjs
Days,
8 8. Occupation,
i — _ .*7 (Return occupation for all persons io years of
§ 9. Pla^Krth^^^y l0
(Return occupation for all persons io years of age and over — if under one year return occupation of fathex.)
Name of Father
3 11. Birthplace of Father,
(State or Country.)
icier one year return occupation oi fat lux.)
x , O J0SL '*27 JzL
tp mull name.) ^
12. Name of Mother, £
•J 13. Birthplace of Mother, •£_
[3 (State or Country.) X ft
of Death, / ' '• - '
(Maiden name.)
h 14. Place
If death occurred in an institution, give the name of same,
Length of time deceased was an inmate,
Street, Cambridge.
, and previous residence,
i4 15. Late Residence, No. ,
\t
'0
Length of Residence (in city or town),
Z 16. Place of Interment, ^xTx^ * - "*
(Cemetery.)
Street,
(City or Town)
(City oryfown and State.)
£
Signature of Undertaker (or other person making the return),
Residence, No.
Street,
(City or Town.)
No. of Burial Permit.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH
Name of Deceased*,
Place and Date of Death
Disease or Cause of Death :
Cambridge, / 's'
sed .X - ' &/lXXx<- Supposed Age, Years,
Months,
.2_
190^
Days.
/{f 0
SliU'CP; Oainhi'WgL,
Chief Cause,
Contributing Cause!
Place where disease was contracted, if other than death,
^certify that the above is true to the best of my knowledge am) )i^l?pf.
Signature of Physician, W ^ * M.D.
Residence, No. ^ (^6>€ — (/ Street, //W4wy// /'XOXso ,
(City or Town.)
Jr Sex of Infant (not named).
ft a soldier or sailor who served in the War of the Rebellion, Chief and Contributing causes must be given.
The office of Board of Health will be open for the granting of permits for burial as follows : Saturdays, 8 a.m. till 2 p.m. ; Sundays
uni Holidays, 1~ • • Other Days, from 8 a.m. till 4 p.m.
I
Acts of 1897, Chap. 437, Sect. 1, 2, 3, 4, 5, 6, 7.
Section 1. No undertaker or other person shall bury a human body in a city or town, or remove therefrom a human body !
which has not been buried, except as provided in section two of this act, until he shall have received a permit so to do from the board
of health, other than the selectmen, or its agent duly appointed for the purpose of issuing such permits, or if there is no such board
from the clerk of the city or town in which the person died ; and no undertaker or other person shall exhume and remove a human j
body from a city or town, or from one cemetery to another, until he shall have received a permit so to do from the board of health
or its agent aforesaid, or from the clerk of the city or town in which the body is buried. No such permit shall be issued until there ]
shall have been duly delivered to such board, or agent, or clerk, as the case may be, a satisfactory written statement containing the ]
facts required by law to be returned and recorded, which statement in every case of an original interment shall be accompanied by
a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. ]
If there is no attending physician, or if the certificate of the attending physician cannot be obtained, for good and sufficient reasons, 1
early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physician employed by J
said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician ; I
and in case of death by violence the medical examiner only shall make the same. When such satisfactory statement and certificate
are delivered to the board of health or to its agent the board or agent shall forthwith countersign and transmit the same to the clerk
of the city or town for registration. The person to whom the permit is so given, and the physician who certifies to the cause of
death, shall thereafter furnish for registration any other necessary information that can be obtained as to the deceased, or as to the '
manner or cause of the death, which the clerk or registrar may require.
Suction 2. No undertaker or other person shall bury in a city or town a human body or the ashes thereof brought into this !
Commonwealth from without its limits until he shall have received a permit so to do from the board of health, other than the select-
men, or its agent duly appointed to issue such permits, or if there is no such board, from the clerk of the city or town in which the
body is to be buried or the funeral rices are Lo be held : provided, however, that if there is a person duly appointed to have the care .
of the cemetery or burial ground in which the interment is made, and there is a record kept of the names of all persons buried '
therein, or if there is a duly appointed superintendent of burials in such city or town who keeps a record of interments, said permit
may be issued by such person having such care or by said superintendent of burials. Said permit may be granted upon delivery to
said board, agent, clerk, superintendent or person having such care, as the case may be, of a certificate giving the name of the
deceased person, his age as nearly as can be ascertained, the cause of death, the name of the city or town where he last resided or
from which the body was brought, or, if the death occurred at sea, the name of the vessel upon which it occurred, and any other facts
required for record which could be obtained with reasonable exertion. When such certificate is delivered to the board of health, or
to its agent, or to the superintendent or person having such care, the board, agent, superintendent or person having such care shall
forthwith countersign and transmit the same to the clerk of the city or town; and if the deceased person was at the time of his
decease a resident of said city or town the clerk shall record the same in the books kept for recording deaths; but if the deceased was
at the time of his death a resident of any other city or town within this Commonwealth said clerk shall forthwith forward to the
clerk of such other city or town a certified copy of the certificate mentioned in this section.
Section 3. No person having the care of a cemetery or burial ground shall permit a human body to be buried therein or removed
therefrom, or permit the ashes of a human body to be removed therefrom, until there has been delivered to him the permit for the
burial or removal of said body or ashes, nor permit the ashes of a human body to be buried therein until there has been delivered to
him a certificate that the burial permit and the certificate of the medical examiner prerequisite to the cremating of said body have
been duly presented.
Section 4. No undertaker shall bury the ashes of a human body which has been cremated until he has received from the
person having the charge of the crematory a certificate that the burial permit and the certificate of the medical examiner prerequisite
to the cremating of said body have been duly presented.
Section 5. Any person violating the provisions of either of the four preceding sections shall forfeit not exceeding fifty dollars. *
Section ii. No railroad corporation or other common carrier or person shall convey or cause to be conveyed, through or from
any city or town in this Commonwealth, the remains of any person who has died of small-pox, scarlet fever, diphtheria or typhus
fever, until such body has been so encased and prepared as to preclude any danger of communicating the disease to others by its
transportation; and no city or town clerk, or clerk or agent of the board of health, .shall give a permit for the removal of such body
until he has received from the board of health of the city or from the selectmen of the town where the death occurred a certificate
stating the cause of death, and that said body has been prepared in the manner set forth in this section, which certificate shall be
delivered to the agent or person who receives the body. Any person violating the provisions of this section shall forfeit not
exceeding twenty-five dollars.
Section 7. The boards of health of cities and towns shall, on or before the first day of May in eacii year, license a suitable
number of undertakers who can read and write the English language, to take charge of the funeral rites preliminary to the interment,
removal or cremation of a human body. Such licenses shall be issued under such terms and upon such conditions as the board of
health may prescribe, and may be revoked at any time by the board Avhen such terms or conditions or any requirements of law
relative thereto have been violated by the undertaker: provided, however, that an undertaker so licensed shall have the right to act
thereunder in any city or town in the Commonwealth.
Acts of 1897, Chap. 444, Sect. 10.
A physician who has attended a person during his last illness shall forthwith, after the death of said person, furnish for
registration at the request of a duly licensed undertaker or other authorized person, or any member of the family of such deceased
person, a certificate, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which
he died, the duration of his last sickness, and the date of his decease; and a physician who has attended at the birth of a child dying
immediately thereafter, or a physician or midwife who has attended at the birth of a child born-dead, shall- fertllVviMt -ft
registration a certificate stating that to the best of his or her knowledge and belief such child either died immediately after biT
was born dead.
A physician or midwife who neglects or refuses to make the certificate required by this section or who makes a false stater
therein shall forfeit not exceeding fifty dollars.
Form 0.
y. dl
Commontaltlj of
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
ILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name J. / ...
Date of Death,
Sex, j/YdY.. „Color, Y _
190/ ; Age,u. V„ Years, 6~> ...Months, *?_Days
Maiden Name, |If“^r^ed[..
Husband’s Name,
Single, Married, Widowed or Divoregil
•Residence, j Sift i '
Place of Birth, /r
•Place of Death, JZ...
Name and
ccupation,
f/
r r
r/
/'r
Birthplace of Father, Y — Aisf/pjfrix,
Maiden Name and Birthplace of Mother,. QApytA j£.s Qi- u£a -Ad caA ay
Place of Interment, (Give name of Cemetery),. ^ //A. LJLJL^t AyJYZAY ^P. 'LsL',
Dated at.. — ^'.L..(yy.(/lHytAst--jZ
on Ls. Hi .1' 190 $ of Undertaker.
JAA.<Zjyi-
Signature and
place of business
UYYIMJKJ:
V
PHYSICIAN’S
Name and Age of Deceased, f
Place and Date of Death ,} died at
Disease or Cause of Death, §
iTl/vvuC L. ffy\o
iCATE.
re, Y. £ Mj J0dT
21/ * /f&V
ui/4(
i-
1 !
Duration of sickness, /h\s\fZ) »
’ I
I certify that the above is true to the best of my knowledge and belief.
bjY ff
Date of Certificate, - 1^^.
Signature and Residence '
of
Certifying Physician. ,
M.
Give also street and number, if any.
f Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Agent of Board of Health.
RETURN OF THE DEATH
O
Ci
3
S3
G
'TJ
V
<0
4=
05
00
H
o
c
-S'
-k<
X
w
H
(-
<
c
o
H
O
•s!
K
H
X
K
>5
Cj
'C
43
3
a
13
43
£
3
t-
C4
_g
3
o
CJ
43
(3
43
<3
43
O
43
C3
3
43
TJ
S3
O
42
<3
bD o
b 43
43 ^
3 O
o
43
fs
3 .a
o
43
3
bD
u .«
K
43
3
H
3
W
CO
>>
a
cS
rt
3
T3
CJ
•
'S
rr—
JG
-*3
O
♦-3
49
c5
CJ
’3
CO
a
c3 co
b 1
o
bD
-
O
c3 ©
Tj
s ^
»-
rt
p
CO
cj
'C a
^3
CJ
C. 3
-*4>
.5 2
rt
3 tn
> S3
rt 43
3 W
43 O
42
O
rt
43
3= fe
rt ri
22
IS
3
43
„ T3
=> O
>5
42
'V .£
O
42
o
p
fml
rt
CO
rt
u-
rt
CJ
S_4
a
■4-3
O
o
CO
CO
u
5
-4-3
bl)
>%
Wt
CJ
CP
CJ
-a
a
*3
"3
CO
CD
>
ca
o
.2
CJ
a
CJ
U-t
^3
*a
rt
k
r©
. CJ
«*-<
n
CO
'G
f-s
*rt
CO ^
•4-3
CJ
bD
CJ
a
rt
-a
-4-3
3*
CJ
CJ
U
rt
a
a
p
s
, as
CJ
u
o
p
cr
CJ
t-l
CJ
©4
-4->
rt
ca
m
rt
CD
43
rt
-^3
a
r )
-p
-30
CJ -4-3
G
cj ^
aa a ^3
aa
a
a
a3
£ G £
CJ
G2
nT
CJ
S3
rt
CJ <1?
^ J
u 3
> o
’Sb O
bD
a
O
cj
aJ
3
cr
cj
bD
a
o
aa
>
.3
3
CJ
* •«
rt S
£ nr
CJ
>> T3
^ a
^ a;
P ^
2
2
oj
a
s
o
rt
aa
CJ O
2 ^
bD
<u
a
p o
>> &
a?
aa
H
p
o<
o
H
Q
CJ
-a
CJ
-4-3
ns
CJ
a
CD
<4-1
O
rt
rC
'h
T-
CJ
3
rt
aa
CJ
O
o
2 cj g y
cd CD
.5 a
rt
CJ
3
^ <D
^ rG
2 1
rl a
>5 3
t: -a
C3 ^
« ^
3
bD
ri
43
3
bD 3
bD
a
ri
43
2 3
43
.22 3
a
4. rt
3 3
c* »
>5
a
-4
3
43
CO
O
H
O
■<
3
H
X
w
.a o
3 3
43 43
-4-3
<4-1
Q
CJ
Ph
aa
-*4»
t-
CJ
-a
ns
CJ
o
oo
CJ
a:
-4J
O
t-4
o
-4-3
-4-3
CJ
bC
i-H
U
a
t-H
U*
nd
CJ
rt
CJ
g
rt
>>
*-)
rt
O
-4-3
CJ
o
o
o
CO
>
o
s
2
CO
03
.3
*5
-4- 3
aa
—2
H
O
QJ
ri
43
tn
o
’« 'a
43
3
a
3
42
3
42
— tn
*3 .a
M S
o
>» ^
'C -b
o
42
3 a
o
>»
■«
3
43
3 .2
3 3
r C 3
a 43
rt -4>
a -g o
3
a 3
3 3
•g <3
a tn
in
— - 43
1 — ■ _>
a
3
43
>
T3
■ a
43 ri
3 *;
tn bD
4 a
3
o
!>> 5
43 rt
24 O
4!
c!
3
43 43
5z
O
>>
%
o
JCA
a <4-4
55
O
H
Q
a
rt
nr
a
H
b
rt O
■§ T3
H
O
W
CD
o
CJ
OJ
CD
CO Ut
>> rt
-2 8
CD
rO
3
43
rt
a
A
CJ
nr
bp
co
O
■o
t-i
o
CJ
-t-3
>>
CJ
CO
a
u-
s
tC
o
rt
CJ
bD
CJ
g
ri
3
3
Pk
•O
«
o
b o
H
O
w
-x>
a
3
3
42
7}
O
PQ
bD
3
Cammonfomllfc ai lltessarkusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name,...
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Sex, ~>k.' ..Color, „ .
Date of Death, / ; Age, ... OOf ears, A Months, O- Days.
Maiden Name, jIfn“^^fewedj
Plusband’s Name,
Single, Married, Widowed or- Divorced,.. ... Occupation,
•Residence, j ««*& gJ5»; j wUJ'UL-fij.Q
Place of Birth,
(A^jU.4dd CX/L
* Place of Death,
Name of Father,
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,.
a f ^ 0 ^144 ^
QJJjAM. ^/ly.QAAL
a, t£, Q&
i . ^oAouaA %LaM:.
Place of Interment, (Give name of Cemetery)
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,!
Disease or Cause of Death, §
Duration of sickness, /
I certify that the above is true to the best of my knowledge and beli
Signature and Residence
of
Certifying Physician.
Date of Certificate,
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
O
GO
c3
Cb
GO
©
co .z.
*
P
P J-
O O
P
o
o
o
pa
+3
ci
ci
o
CA
P
o
P3
o>
CA
O
*
P
c3
0
rP
c
CO
Cm
o
*M
o
Q.
.2
HP
3
rt
a
o
ir
*co
pa
o
O
CO
O - S
^ <«
«M *“•
c .2 «
2
/—s
ci
+3
3
■4J
00
CA
cm
o
rt
p
o
"*■*
a;
.2
Q>
+3
Z2
bp
pa
o
0)
4-J
o3
gS
o
CA
a
<y
QJ
CO
~ 2 bD
o
co
-4-9
o
<1
p
O ^3
p
P CO
c3
O
P3
4^>
c3
£
O -S °
o?
pa
a?
cc
p
3
c3
rP
0> O
P3 P3
«-* 2
C5 ‘Ps
P2
O
a>
P3
m3
O
.2
nr
a
CJ
>
c3
3
■4-J
cm
c3
.2
*4J
o
p
o3
pa
o
a>
d, or
p
<D
>■
o
CA
<D
o
CA
3
five
CA
a
a>
,
o
CO
>>
G>
<M
a
CO
<P
CA
O
*G
cm
P
c3
ci
CO
4->
O
CA
In
a
P
*P
O
c5
mO
*M>
o
o
P
cS
<W
3
CA
P
O
CO
CO
o
p
cm
np
o
g §
3 «
>» >>
"C —
2 ts
o
P .2
ci P
S ^
2 2
CA
P3
4-9
o
P3
4^
£
fc-
2 3
c
<y
a>
P3
P3
o
p
Q
+3
o
<u
CA
<D
O
CO
0^ G *-• *_<
*5b
cr 'o .2
o
bD
O
CU
a
P3
O
ca ^
» c3
a
c5 «
<x>
o
s
o
<D
H
p*j
Cm
o
M
a>
P
C >>
Cu rt
CA Pt
o .2
PJ
o C3
^ I
■« o
<« «
o Q,
■a h
o
o
44>
o
o
P3
-4-3
CM
O
53 +2
P5
o
c;
o
4-9
o
PS
cm
'P
<D
o
a
P
c3
3d
<D
o
o
4J
M>
c3
rH
.2
o
p
bD
3
o
CO
c3
J
c3
&->
O
o
—
o
P3
4->
CA
c3
bD
a>
O
•Sb
CA
.2
3d
pa
a
P
>•
<u
p
*
a>
c5
o
p
2
o
«M
o
P
o
<M
>>
o
«
P3
CA
cm
>9
CA
H.
<D
p^>
*P
4->
3
l^s
3
3
G
>>
Tj
cm
P
pH
<1
Ph
to
O
p
cr
o
^4
rf o
< i>
o
p
rt
HP
o
o
o
C3
P TI
O
P2
<D u
o
pa
Commontojealtfe flf
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
sr\ (FILL OUT WITH INK~ ALL NAMES TO BE IN FULL.)
Name, l ///C>G(4A{iA Sex, Color, W
Date of Death, • fC f> (HjLwt : Age,. A^ffPS, e/ Months,/ Day/.
Maiden Name, ) If m^vd^owed j lArr: zTA-rr. f .
Husband’s Name,- <^^...^.^.1 17....ZA . ~~T
Single, Married , Widowed ,or Divorced, zJ.. Occupation,
•Residence, ) aisoTme fuTiy! | (? £ (^umv l ^(nejw/j^
Place of Birth, /~\y ' ’
•Place of Death,
Name of Father, 9ti WlJmI Sou.
Birthplace of Father, -2
Maiden name of Mother, 0>V^m<nd/
Birthplace of Mother, y^LAyQjL
Place of Interment, (Give name of Cemetery),
J I'CAltfc^ - Signature and ( A ^htoi / dj-.
^ / L" n/*^ y§ of Undertaker. I - 0^(aMuj> A 'TMjzw.
on
PHYSICIAN’S CERTIFICATE.
Name and
Place and
H. V. REYNOLDS, M.D. 29 MONADNOCK ST.
^cntoM rflfauc.
Disease or JJ, , f) . \ i
. 7tJ- . 0>»?
A*.
Duration i
I ci
Dat
Give also stii.
t Or sex of inf
§ If a Soldier j t
) vCy, CjL^s'p'
^
^ A Vv ^
atI . U.iU T..U,
L/ l }
Uujnw> .
m
UJ -
M D.
189
M. D.
RETURN OF THE DEATH
C
00
r3
I °
a
a)
c/3
a
o
c-
5
a
o
o %
c3
O
<D
aa
^ ^ 00
CD
bfi
q
73
2 cj
o
cd
CO
a
a
C/3
a
a2
X
(U
o
0)
>
CD
3
ca
aa
-M
rH
aa
CJ
bD
>>
3
o
<M
>>
3
>
a
3
+3
a
o
a
a
Cm
CO
CO
(D
>
3
c3
3
0)
2
3
o
O
CO
3
-*J
o
aa
3
O
CO
2
+3
«*-*
o
a
*-3
o
CD
q
<D
3
CO
a
.2
CO
CD
a
o
3
CO
Ga
V-»
aa
S-»
G
0)
CD
£
o
,h
a
CO
Ga
CD
q
<d
-M
-1-3
CO
-*3
•
cr
CM
C/3
a
co
o)
«m
O
o
v — '
CM
O
T3
Cm
o
a
Oi
CO
05
a2
e °
Ct rM
.2 q
£> 5
a* a
c; T3
a
C 12
CD
>
S-
3
-M
Cm
q
a
o
a
3
q
3
aa
4-3
+3
a
ED
o
CO
-4-3
<D
s
CO
cd
0)
C/3
a
3
cr
aa
o
ci
3
>>
T3
O
a
o
o
a>
co
>>
a ^
""' u
a> o
a3 a3
bD
a
o °
a
a q
'M o
CD
2 -s
*bb
9
o
O
5"
CD
Ui
CD
3
<u
2
co ^a
aa
G3
CO
-iJ
M
a
.2
o
a
CO
a
CD
C/3
cd
bD
O
<d
a3
a
3
bD
a
a
a
— ■
CD
a
ri
aa
4^>
q
<d
aa
aa
o
•r a s
.2
3
a
aa
o
o ^
§ O
.2 *=
A
H
ps
.9
a
£
o
+j
o
‘o
«
o
S
o
bfl
^ >»
a "a,
'a
a
CD
O
4-T
o
CD
1 8
a
CD
q
3d
2 8
-*-3
-4-3
c3
a
.2
<D
a
O O
+3
CO
q
o
.tf «
rt
aa
3
CO
3
O CD
c
*bb
CO
3
. 3
if
•2
a. q
a
q
s
a
o
o
a
aa
H
a
aa
o
M
s
3
cd
O
o
bD
t- a
q o
aa a
O q
rd
bD £
a o
a
> o
rt ci
aa
a
a
o
CO
a
Ef
C
+3
u
o
-•J
*3
<d
0) o
“ .2 >> <u
p-.
A
CU
ei
a
a>
C0
a
2
2
°* s
S>>
O <y
o
CG
a
cr
c3
CD
aa
Form C.
Commonfomltlj of lltassatjwsetls.
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name,
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Color. ^
/PJ.9, Sex, Color,
Date of Death, It 1906 ; Age, SL Years, ^ Months, .Days.
Maiden Name, } K ( 6£?.Jkcid£, 0-1 Z I k/uUIsU
Husband’s Name,- /A
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,!
Disease or Cause of Death, §
Duration of sickness,
I certify that the above is true to the best of my knowledge and belief.
Give also street and number, if any.
f Or sex of infant not named. If still-born, so state. J If child died immediately -after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
No
RETURN OF THE DEATH
0
01
O
Ci
a;
P
ft
03
P3
•*3
*-> jzs
01 «
£ «
03
P3
•*^>
P3
2
*P
^3
□
o
rt -c
03
O
P
03
T3
03
V-
CO
b J
03
£
►» 5
•e 5
03
be
t—
O
o
p:
5 o
a 'o
03
> .2
p
P3
y
CO
p
03
"5 a
~ <u
P3
cp lp
03
P *P
PC
a (p
a>
eo
<d
k 2
a 03
^ oT -&*
Cl
00
ei J>
H
Cl
c
v
15
&
a>
.3
a o
K
W
H
&<
<
B
O
^ 3
3 .tJ
cj
O
35
H
ci
C
3
H
K
w
3
O
-3
O
31
£
•3 01
I ^
o
.a
03
P3
o
03 (JO r>
► P
P «p
- fe- 5
O *C
rf| 03
be
TJ
fl
K
rt -rt
o £
H
O
W
CO
>>
a
P
.22
2
03
P3
>1 *
TL >>
U
G3
'C
c
p
a
o
OQ
s-.
0
<G
o
'P
03
-4->
*4-4
P
O
rO
03 O
O ^
be a
03 P
a S
5
03
P3
'P
03
.b ^ -3
cr
a
03
P2
P
p
a>
cn
&
P3
O
’Sb
p
cr
o>
- ^
o
pp
03
3
£
•p
a
P
a
c
o>
£
o
p
03
-p
CO
3
a
03
Ph
•u •-? •— ■
a>
CO
p
cr
P
03 03
— < <d a
a;
a
eS
co
3
c5
3
Cl
- fc
■« °
2 °
a a
« a
> o
tfl o
iS 33 32
fcJD
3
03
rv
l>-
C3
•O
^ "tf
03
03
h
oo
r—i
rt H
bo
P
a
o
03
ra — •
o
■4-2
C3
O
o
^ C3
P P
4-2
O
P3
w
H
a
03
Sh
P CO
2 a
a
"p
•<
U4
03 03
5 ^p
p
03
t-T
O
.2 P
O —
.a =
03
-a
p
cr1
be £
a
03
P3
CO
o>
o
-P
o
P3
fc*
P
P
o
S -*
p o
5 p
£• p
03
>> p
p
o
cc
s' t
«
a
H
P
◄
ffi
o
P
P3
03
O a
c
bo
•- o
03 5
2
3
C3
p -a
c.
p
O
o
o
be
C3
P3
2 ^
p
P3
O
H
O
◄
«
H
X
w
P3
O
P
P
03
*
p:
03
be *2
a
o
*ru p
be o>
be
p
>
a
P3
P
p:
p
o
CP
O
>> P3
*03
03
P3
H
p ^
fl ,
Ph s
00
H
O
w
CO
o o
03
03
P
cr
03
3
-5 b
03 »
a <!
a
'O
o
p
p
03
be
p
a,
o
p ^ —
>> a
03
p:
p
o
P3
O ^ ^
o
5?5
O
P
03
P3
P3 M 'TJ
p
03
H
Q
a
GG
O
>>
P3
P
o
P2
H
O
w
CG
*o
03
P3
.£ 03
o r
03
D,
03
P3
O 03
-a pq
p
o
PQ
QB
a
0
-3
S*>
*->
a
bD
3
3!
0)
ai
o
K
ci
e
•3
ct
03
a
a>
&H
s
u
03
to
Comma itiuealtk of Ptassarfensetls,
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Maiden Name, j If m^divirTed?wed
Husband’s Name, ...CL..
Color, 9^
^ Months , ( \J)ays .
Single, Married, Widowed-or Dworuod, Occupation,
* Residence, J ILnta°te*f uTi?’ | 2 3 V QaJUa, UJL^
Place of Birth, y^/ .
* Place of Death, Zk $ £
Name of Father,
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,
Place of Interment, (Give name of Cemetery),
Dated At
on
feZtoSb- /&*
Signature and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, f 'sits'll- Age, ..jfc. Y 7 M.— D.
Place and Date of Death, | died^at
Disease or Cause of Death, §
Duration of sickness,
Signature and Residence ‘
of
Certifying Physician. ,
A**
I certify that the above is true to the hest of my knowledge and belief.
i/
Date of Certificate, 'Qjjcdl „L*?*~* „
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
■+3
CS
05
GO
03
*ci
«
a
O 42
C
» .2
4 -3
3 3
O *5
-a -2
ci
a
-a
<4-1
o
"p
3
O
rO
- o
a
co
D
O
^3
O
co
O
-3
£
O
<D
co
a - a
o ^ >
^ 2 -a
&S 4T
« !3
> C3
« o, OJ
*» is •»
2 .. 3
rt
o
J3
a
o
CU
3
CO <*-«
3 O
ci
CO o
a
a 73
03
*5
a
73
^4
00 *
*5
4-3
O
4-3
ci
03
§ °
-a
o
03
73
£ ^
be
3
a
03
03 C5
co S
"3
-a
CO
o
w
CO
03
03 ^
03
CO 2
>9
73
o
*-S
4-9
«*—
4-3 ✓ V
-a
CO
03
**—
ci
o
a
73
03
75
CO
03
CO
03
449
03
03
a
>
3
<4-
ci
a
o
-a
4-3
*4
o
o
73
o
a
a
o
CO
s
4-3
CO
O
73
03
-a
44)
T
49
03
a
CO
a .a
ci a
S cr
§ £
QJ —
Cu
>> *0
a co
S CO
" o
a ^
U
'I §
cr
a ^
?H o
Lr -a
o
-a
44)
ci
<D
CO
-33
.2
£
■4-3
C3
-O
o — '
7^ q ^
<13
-a
a
<1
o
*<*
cu
ci
-a
a
.
03
c3
CO
.2
03
*4
.2
73
q
03
fe
4-3
a
03
a
03
a
03
a
o
S
g
03
be
.5
o
*5
g
*5
a
‘be
o
cr
73
7S
a
O
03
a
03
T
a>
03
o
a
03
CO
73
a
cr
03
ci 72
O ^
«3
.9
IS
ci
-a
03
-a
H
o e
73
03
4-3
-33
.2
T
.S
a
£
o
44>
?4
o
>>
*3
-a -a ^
fl
IS
-a
44>
o
«»-.
a bo
03
-a
bD
O
03
03
a
o
bC
a
a
a
-a
a
a
a
o
-a
44)
c3
<4-4
o
V
QQ
53
a
75
O
M
tv
74
c3
H
O
&
5
03
-a
4-3
<4-4
O
^>9
c3
73
a
ca
73
a
a
44)
4-3
a
3
a
a
<4-4
a
a
o
s
a
a
c3
To
a
o
a
44)
44)
C3
a
.2
a
a
be
o
(O
c3
73
c3
o
ci
-a
a
44)
a
-a
44)
CO
c3
be
a
o
‘be
CO
a
To
a
V
a
a
<4-4
a
T
ci
a
-4
-a
^4
o
<♦-•
a
.2
a
a
<4-4
ra
*4
o
<4-4
a
o
CO
03
03
a
ci
V
o
a
a
ci
-a
£
o
>>
4-3
‘5
03
73
<4-1
o
M
a
03
>9 “
4-3 K^,
s ^
n *— 1
.22 t>> 03
CO
03
73
a
cr
ci
£ s
a
^ o«
a
ca
03
03
-a
o
-a
44)
T
03
-a
k fyL3.
Cammonfoedt^ nf
Name,
Date of Death,
RETURN OF A DEATH.
To the Clerk of the City or Town In which the death occurred.
Wl™ INK* ALL NAMES TO ee IN FULL.)
Maiden Name, j If married, widowed
( or divorced.
Husband’s Name, ^ „
Sex, Color,
; Age, f Years, V Months, /^Days
SiDgle’ or J)ivgiu^. -Occupation;-
^Residence, i out of town, i
’ ( also state fully, j c
M.
Place of Birth, //c2. /3 (Hr \S UxJL/
* PI ace of Death, ^ £L / 2 ^yyc^cT^V 5 ClZjl/
Name of Father,
Birthplace of Father, Jr, £3 r
Maiden name of Mother, /\J
Birthplace of Mother,
Place of Interment, (Give name of Cemetery)
Oil
Dated itt SryviZtiPiAfi Sl5„,ure»a
w / £ 'r £ / P^ace of business
PHYSICIAN’S CERTIFICATE.
Xame and Age of Deceased,) I Jt&Ub.' 'f- jj 4o.e •
Place and Date of Death, } died at kf'
Disease or Cause of Death, § \\uJl
M. D.
l^r.^
Duration of sickness,
I certify that the above is true to thi best of mv knowledge and belief.
Signature and Residence *
of
Certifying Physician. ,
Date of Certificate, I 1
l
Give also street and number, if any.
f Or sex of Infant not named. If still-born so state + tp mu ,
I » . Soldier or S.il.r 1„ „« W„ „,c ieOemoo.' ‘bo.h “SX* "
RETURN OF THE DEATH
O
Ci
GO
Ci
00
n
V
c
.2
3 3
y
§ i
32 -2
O
32
a
a?
CO
s
o
CL.
3
OS
o
32
Ci ^
•2 <*>
-4-3 ^
■4-3
O ci
•4-* Ci
ci ^
to M
“* o
O ^2
rt
2 w
a
3 r£
!§ «
& 3
3- a
a
*S
4-3
33
o
ci
Ci
g §
« «
>3 ^
T3 ^
Ci <1) <D
^3 ^3 Ci
^ +3
* 2
o a
o
«
C/3
3
O
33
>>
3
3 •
3
O
Ci
CO
Ci
>
CO
ci
2
3
lx
oS
■*->
<*—
ci
3
.2
a
3
"c
‘■4^
3
ci
^3
33
Ci
Ci
3
O
;/.
f/)
Ci
’5
CO
<4-1
bJ0
T3
ci
>>
3
ci
3
ci
O -
>>
3
ci
<4-.
O
-3
ci
C ci
o
<1
o
C«
ci
33
Ci
3 . *23
.2 ^ ~
■*-> ri
o Ci o
Ci r— .3
«» 33
« 2 ^
-4-3
CS
33
-1-3
"ci
Ci
£
3
O
a
a
o
O
Ci
Ci
CO
co ^
Ci
CO
.2
2
3
cr
Ci
33
Ci
be
O
bfi
be
3
>>
3
3
Ci
a
Ci .
S-. •£
CT 'w
Ci
*"• a
Ci o
Ci
Ci
CO
£
«4-»
3 O
O £
— ^
CO
r ci
o c
E. a
o
Ci
H
3
£
O
o
>>
*3
Ci
Ci
Ci
B
o
.5
3
ci <g
bO
3
3 3
ci O
be ^ ^
ci
33
CL ci T-
ci
- 75
3
a
a
c
o
Ci
-3
H
ci
33
o
t
a
a
be
O Ci
rz 3
3
3
2 ^
^ 2
■4-3
Ci <4-1
Ci o
bO ci
£ l»
ci
S -3
o .2
P
J| £
.a 33
33
O
<4-t
>4
-*->
"ci
3
Ci
co ci
i- r—
a ci
£ s
3 ci
Ci
CC
Ci .X
'O 33
"3 £
3
cr
ci
Ci
3
ci
"y
o
©
SJ
3
33
Ci
13
£
o
33
O
33
-4^>
75
Ci
33
[T.’OO-ST-XXM.]
hj
Permit No.
RETURN OF DE
Year, /?>'»
Date of death Montltfr^fa'P Birth
1 Bay,...pNf. fP.
' A-r r
Name in full,
Maiden name,.
f Single.
j Years,
f>e i Months,
Residence
Sex
-ftp n. 7 .-I
Female.
Conjugal condition {
J\htrrird .
W*bdowed.
Dvr>ei l 'ed.
f White.
I Bfack (Negro or mined).
Color i Trrd imt .
I /' /
I w ^ .
IFZ/e o/.
Widow of v - —
PZace o/ deataj ^ree*/ *
* 1 N umber
Place of birth,
Occupation, ....^.^.
Name of Father, *< Maiden Name of Mother.
Birthplace of Father,
Place of interment,.. ([
Birthplace of M other
y (9cUA^J > @e^goly(7
PHYSICIA
tCATE OF THE CAUSE OF DEATH.
' ^ r NA 190
Name and age of deceased,
Date and place of death,*
j Chief
Disease
cause,
Contributing cause,.
xNNl a:
/Igp, years.
P'/y
j Chief cause, .T....^77
Duration i
( Contributing cause,.
I certify that the above is true, to the best of my knowledge and belief.
Name and residence { Zfc Z
of physician, J " ' / C f ^ ' V sZZ .
*If in an institution, state how long an inmate and previous residence. Pf -/C f f'Cx r PC' *
The office of the 8oard of Health will be open for the granting of permits for burial, as follows : — Saturdays, 9 A M. till I P.M., Except during the months of June,
July, August and September, when the office will ba closed on Saturdays at 12 M.; Sundays, 10 A M. till 12 M. ; Holidays, from 10 A M. till 12 M. ; other
MD.
days, from 9 A.M, till 5 P.M.
-
■
Cammoutaltfr 0f lltesax^itsetls.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Na mo, 2^0 A' — Sex, C ~f~~ Color, %
Date of Death, I y^QjjUAjJk^ S/s> ; Age Years, / f Months, 42^ Days.
Maiden Name, j If nio”d?vir«d?wed | ± Vt V eJ~~
Husband’s Name, ^’c/Xa^CC-' r ^42 ^4^0
Single, Married, Widowed or Divorced, Occupation, ‘
* Residence, | K | J -
Place of Birth, -X/^ ?V ,
*Place of Death,
Name of Father, „ ( C'&L
Birthplace of Father, r X t /
Maiden name of Mother,
Birthplace of Mother,
Place of Interment , (Give name of Cemetery)
Ov r7
. s' PXAS^t .^(M/
Signature and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, f j sAc'-vA* Age, J?3-Y. M. /a&SD.
Place and Date of Death, J I died at — .. .^ , »AAaaa..~.
Disease or Cause of Death, §
189.
Duration of sickness,
uy
£Ls •-f i H .. crS '
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence ‘
of
Certifying Physician. (
/Qo~u
Date of Certificate, ifo- .
b* M. D.
Af/y<L^
. A—
J2/.1. u/'sul &A.
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. { If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
I J
\x
C\
\.
^ r
as
o
fc
I
H
<
UJ
Q
UJ
I
H
Lu
O
DC
D
\r~
UJ
DC
C3
CO
es
CO
-3>
rt
a;
H
a
^3
3
a
oT .9
3
3 3
o
9 *-3
O 03
C
33 —
-*-3>
c3
02
_, «4-*
% °
o
a:
V*/
C£
5
r^
rH
<12
*rt
C5
«4-( ^
O 3
aa
00
to
02
<u 2
o
■*->
ca
a
<4-1
o
CO
bD ^
•*-J
C2
o
a
o
1 2
31
<D
bD
‘-*3
o
02
-43>
as
fl °
C3 r—
;§ s
£> 5
33
3- a>
c; 33
33 ©
a
33
O
o
33
*
3 O
0}
a>
<D
CO
J ®
« “
>> >>
-a 33
J -a
o
3 .!=
o a,
2 33
O ^
o:
p •- 03
O 'O >
J 2 '5j
a > £
s '? ~o
a es 'C
O ,,
■c
a
2
2 ^
p-> 2
C2 CO
P 02
/""N S3 q
CO
02
02
c n
a 2 CO
cr
02 <4-4
*-« o
ja
o ”3
CO a
O a;
O ^
02
◄
O
TS»
a.
ri
^=S
a
a
«*-i
rt
to
P->
rt
02
<G
a
S
02 r— .a
o>
a
cr*
02
02
® £
a= o
a
cr
02
02
aa
>>
•~
C3
02
aa
-*33
a?
bD
O
o £
.a ^
bD
'a P*
bD
a
a b
S “ ^
o
U « a
o
a>
o
CO
cr
<u
^5
02
02
aa
aa
CO
-^>
■3
02
CO
.5
aa
02
>
c3
a
«4-l
6
G
c
0
02
02
02
p-
o
0
e
o
>>
-*->
-*-»
4-9
O
bD
o
02
bD
3
33
C>
„ 33
2 o £
eJ
*-J-3
'C o
£ S
3 c3
3 3
„ 5
O .-£
bD OJ
° be
3 £
OS
O o
—
'bD
“ .2 >»
tb 2 w
"S j- 3
fi
T PH
3
cr
bD
a
'P
ri
33
3
3 —
O
03 <D
t- '■p
9 3
s 5
a ©
C *3
o
<G
a
£
c
■4-3
J-H
o
*o
02
02
o
aa
-*3>
o
-4-3
O
-a
[T-’OO-37-XX M.]
Permit No.
RETURN OF DEATH.
BOSTON.
f rear,/?«°
Year, / ? Y ■
Date of death j Month, Birth
Month, ' . *4ge j
1. Day, Y
/I /l /I
Day, .... f 1
Name in full, J; , YCru X ■*>-*
Besidence, ^ Njl.
Maiden name,
Years, /r
*7
Months,
Days,.... Zr 4?
Male.
Sex
iPemttde.
Conjugal condition
Single.
Manned.
Widbwed.
Divorced.
White.
Bbacly (Negro or mixed).
Color i Inad/m.
I Chinese.
I Japahese.
Widow of..
CC CCk. t
Wife of
Place of death j eet’
‘ ( Number,
Place of birth,
Occupation,
Name of Father, fO i « Maiden Name of Mother,,
Birthplace of Father, j ■> Birthplace of Mother,
Place of interment, fClp/pfCgf... Tdf <r%_
CL //tJiAAXJg&-
uc* rr^
Ou^MLj '
Undertaker.
PHYSICIAN’S CERTIFICATE OF THE CA,USE OF DEATH.
Boston, 190 C .
Name and age of deceased, / (C C tc J ‘ L Age,. . CJC years.
Date and place of death,* df j/C ^ $ Y ' ' ^ ^ '
( Chief cause,. CfcLFN.
I Contributing cause,. C. \.t
( Chief cause,.. ^ Y.
/ 'a -y
'J~v
Disease
Duration
cause,..
Contributing cause.
ir
M.D.
I certify that the aboyf is* true, to the best of my knowledge and belief.
Name and residence ] / 'XfvUtlu/ fd~
of physician, J"" //f f / / {j rr ^ ^ Xc
*If in an institution, state how long an inmate and previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows : — Saturdays, 9 A M. till I P.M. except during the months of June,
July, August and September, when the office will be closed on Saturdays at 12 M. ; Sundays, 10 A M. till 12 M Holidays, from 10 A M till 12 M ; other
days, from 9 A.M. till 5 P.M.
I
'
Cammoniuealtfr d lllassax^sctts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK,. ALL NAMES TO BE IN FULL.)
Name,
Date of Death, c2/V f ; Age, 'N. Years, Cd Months, e2/J^Days.
TVTai/lon Nornp i If married, widowed )
Maiden isame, j ordivorceci. <
Husband’s Name, •
Single, -Mftrricdr-YMdowed or lli voiced, Occupation,
•Residence, j ll,”*,,0,'. fflj: | 1 J/f Z'
Place of Birth, 2 y
•Place of Death, 2 4 CldtPL !'//’•
Name of Father, ,yir Co
Birthplace of Father, *?^U2. ’^O,
Maiden name of Mother, c*
Birthplace of Mother, . tsJVw*-.
Place of Interment, (Give name of Cemetery),
Signature and I
s R.i xfV'M* p«— r [
Dated at
on J
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
(a£c^~~*c Age, Y (■ U.M.
D.
Place and Date of Death,! died at
f ^a£&~
Disease or Cause of Death, §
Duration of sickness, | ^44:
I certify that the above is true to the best of my knowledge and belief.
/ d. ^~t±Uc^ ^
Date of Certificate, ^.^*1 /^.^A-89- .-
Signature and Residence '
of
Certifying Physician. ,
M. D.
Give also street and number, if any.
f Or sex of infant not named. If still-born, 60 state. J If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
o
<d a
c;
GO
fl
+4>
r*
Q
a?
iz*
w .2 °
*-< —
§ 3s
O co fl
-a -2 ^
rt fl *q
fl rt Q
"fl r— *
«*-< .w
<S o 3
D D 9
co &C
O a Jj>
- o *"
o> _ o
co a aS
-
o
o
as
a
o
'tJ
a
A
CO
o
a
CO
a
o
a
o
CO
— H
a
a
a
3 8
CO i-i
s-« CJ
<D r*
3 73
2 ^
.2
*4-3
cs
3 o
co
o
fl
oc
fl
T-^
O
>
-fl fl
bO
"5
L5 fl
CD w
£® as
2 -
"y 3
_w 53 c/D^
-fl ««_
^ rt
-2 CO GO
a >
3 -r
^ rt
00 1/2
I °
o 5
s s
rt
<D
4-3
CD
CD
-4-3
c
*M 443
rt
CO
■H 'C fl
r-. O
cr
CD
c*
00
o
CO
a
<!
CD
>9
rt
<4H
O
-fl
443
rt
(D
A
2
«*-. CD
° 3
CD
4-3
rt
-fl
A
CO
fl
.2
*co
w
-fl
H
a
43
fl
CD
CO
CD
A
TO
«*— i
o
CD
4-3
fl
"fl
2
73
a
4-9
S+-4
fl
CO
;>>
fl
a
i>
Cfl
_ C
fl ci *fl
o
co ^ cd
P >
£ 3 ^
>> *3 t>T
C co
ei CO r-4
44 QJ ^
t4_ K' 2
o (« rt
a: 3 »
4-3
o c; 7)
CD rn -H
CO H
a
.2
-4-9
A3 A
443 Q)
£ W
-fl CD
443 CJ
o »
— o
2 ■*3
73 o
4->
fl
’a r-T
4-9
-O
° 5
* S
a w
>> >*
"fl 7G
o
-fl "fl
A
a .b
fl s
S ^
§ 2
CO
CD 2
A
-fl
£
CO
CD
CO
fl
.2
73
a
CD
^ 4-9 CO
rt
O^O
« rt «
2 a
- <D
fl CO
-fl 4-3
CO fl
fl
co ^
S
-2 2
„ &
44) qj
co -ic
fl
.2
3
fl
fl
CD
fl
fl
O
g
CD
bO
.2
O
Vi
CJ
o
fl
P
s
J-i
’§
bO
r->
bb
o
&
"fl
^fl
443
o3
O
fl
c
7-9
44)
fl
CO
fl
rt
a
fl
o
"fl
-fl
-fl
co
a
.2
73
fl
CD
CO
CD
CD
CO
>>
rt
-fl
-*-9
£
CD
-fl
bO
o
co
<D
-fl
443
>
3
CO
CO
.2
•-fl -4
& rt
fl fl
CO 12
co +j
CD 7-
O
"fl
I e
44> O
A
fl ^ "fl
«f-H ^ fl Q
O O § «
o
CD
S-l
O
fl
44>
rt
fl fl
CT3 Q)
73 'H
s tf
a ^
&c
fl
rt O
CO
rt
-fl
O
tn ° - o m ®
fl <p 00 -fl fl a
% -fl g 6: " ^
443
M
fl
G
fl
fl
o
'fl
fl
rt
a
n
<*-4
O
M
o
<4-<
2 ®
!§ as
G
O
-fl
4->
rt
443
«44
o
o
fl
>-)
44)
tn co
^ g
co
fl
"fl
o
a
3
rt
a, a
fl
as
A
fl
«<-i
r' f
rt
Eh
-A
Ph
< -
u<
O
44) -fl
co 7^ fl
a .2
7 j fl
"3 & 5
CO
fl
fl
cr
a
Sh
rt
fl
fl
Ph
o
fl
bo
rt
-fl
fl
bO
.2
k*-
rt
-fl
G 1
O
2 «
g
>%
fl o
<! ■§
6
CG
-fl
.2
3
Ti rt
CD fl
fl -fl
Cammonbxealtfr of lltessarfrusetts.
No.
v-y
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
'ejdeJjii. I Sex, S^. ... Color fr'
; Age, (\ Years. Q^JVIonths, J3 Days.
Name, ,
Date of Death, (J^)\
Maiden Name, |Km$^)^wed
Husband’s Name,
Single, Mwji^d-p-Wi do v.
*Bpsidpncp I If out of town>
xvesiueuce, j alg0 Btate fully_
Place of Birth,
* Place of Death,
Name of Father,
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,
Place of Interment, (Give name of Cemetery), (Qt
QkMi
Dated at
on /
? ' JQM
Signature and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
/O
Age,
Name and Age of Deceased, f
Place and Date of Death, J died at VC y^/Y^- ^
Disease or Cause of Death, §
Duration of sickness,
ertf / A
Y. M./Jfc D.
*
I certify that the above is true to ttte best ot my knowledge and belief.
Signature and Residence '
of
Certifying Physician. .
Date of Certificate,
r
£>
.i#f^
M. D.
£fl.
Give also street and number, if any.
t Or sex of infant not named. If still-born, so state. X If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
RETURN OF THE DEATH
1
o
CO
00
cT
-*-3
Q
ai
GO
H3
33
Form C.
„ ££ .
Commonfaxealtfe nf lltassarbixsetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(f/' V
Name, CAf A.l/IA .. r Hf... ^ Sex, %/.. Color,
2@y}T^ aAi... 190 C ; A-irey.
Date of Death,
Maidpn Name S If married, widowed
lYldlueu j or divorced.
Husband’s Name,—
Years, Months,
.Days
.tL*
/)
//
7
-rSinglo; Married, Widowed or Divorced, ^ ^
* Residence, ) ft™; [ / ^ c^OH7fQ/VVU 19^ , Cjd &s)A UH , Q/, *J\/ C cA^Olyylcte
/ ’
r.
//
Place of Birth,
•Place of Death,
Name and Birthplace of Father, ^ HAj
Maiden Name and Birthplace of Mother, J/ ( (A Aiy t )>J (A ^A A-*- /A (fit <J u ViflflJXitOj
Asl l.( /q 'LJ-l ■-CL&.
db L
‘JU
Place of Interment, (Give uame of Cemetery),
r
Dated at
on
Signature and
190 # Pof Undertaker. ( (^/l/ ) ,{/(7 /• y
4 UMdMS:^
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death, died at
/0
Disease or Cause ( ^ r*mai> ,
of Death,! I Secondary,
Age,.
Y. M./l’D
,/J^Ja.AJ? 190D
Duration,
s
Duration,
7udia (
I certify that the above is true to the best of my knowledge and belief.
A
Signature and Residence
of
Certifying Physician.
M. D.
Date of Certificate,
j '/V?< tkjLLl
190/ .
* Give also street and number, if any. f Give sex of infant not named. If still-born, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
&H
O
o
Ci
O
Ci
a>
o3
a
*75
OJ
Ci
oo
H
C
<5
<3
a
H
£
◄
H
U
H
O
C2
H
«
w
o
.fl
<3
33
<3
*a
33
o
33
£
0?
33
a
<u
72
D
O
O
33
£
.2 %
o
33
^3 o
t? ^
o> *£
> *— <
W oo
H
Q
W
CO
d
<3
•73
O
15
£
o
33
rt
<3
33
rt
O
33
<3
<3 .5
bO
33
+3
d
<3
d
33
<3
3
d nj
rS ^
'C -S>
<3 •
33 33
rt
o S2
0) X
be y
i: 3
a tfl
c3
2
-S3
a
s-
<3
73
d
a
<3
W
o
o
d
d,
.9
2
33
CO
o
d
o
CO
2
-
>»
s
O
X
a
0>
T5
Q
x
fe
*? C3
O O
a a
<u g
> o
'Eb o
63
X
a
IS
63
a
E
o
bB
33 v-<
3
d 33
a s
1 13
O -2
e3
o 02
£ .-S
T3
73
a
cS
CO
2
n
5
2
S
73
*c
a
33
<3
.a 3
el
X!
O
63
X
63
W
O
X
!>>
TJ
O
X
3 'S
rt t_
>>
33
s. rt
d
O -s>
73
C Z3
5 ^
33 <3
b0
*
33
^ S. g
t'-T
73
2
CO
(3
33
<3
O
a
Sh
<3
a
d
33
c/J
-s>
o
c3
<3
-S3
2
a
co
CO
«•-(
32
a
<3
<3
a
73 — £
Si
£ 73
o *£ :-
cr
<3
33 33
<3
33
be
a
73
bC
a
c r*
(3
-* rt
£ 73
rt
O
ca
5 o
2
2
a
33
>>
73 53
3^ O c3
*— GJ
d «
£ x
6}
be
cl
X
3 y x X
y o
Si x
be fc
be
be
a
a
u. 3
o 'o
a o
a
x
CO X
>i a
a ft
3 ^
a
% o
a
C7
<M (3 --3
55
-*->
55
15
55
55
O
ci
o
o
d
O
O
H
<3
H
H
o
H
5
H
Q
33
o
C3
33
Q
73
O
a
a
a
a
a
a
a
co
O
CO
CO
CO
o
<3
CO
2
a
o
<3
CO
5
CO
Si
CJ
o
(3
33
p t
-s>
•5 73
5>>
33
<3 <3
33 33
Ci
00
- 33
d d
(3
5 73
H
O
◄
<3
S3
co
O
H
O
◄
»
H
K
w
(3 03 o
> C5 £
d 33
r.
33
- O
►*
33
33 3
<3
C-.
<3
33
73
<3
Z ^
x
a
t o
o ^
2 >»
ri .u
O j «
r a
<3
33
d
33
<3
ci
33
. d
m o
Q CG
73
32
>>
(3
a
•s>
s
73
’3
&
<3
s
<3
<3
a
33
Si
-S3
as
o
rt
<4-1
o
a
jn
*•23
M
Si
<3
r1
2
s
5
2
(3
-S»
rt
73
0>
<s>
a
33
CO
ci
-x>
— 2
H
O
w
CO
<3
33
73-33
73
a
ci
a
be
<3 2
vW
>>
t-i
o
33
<3
O
-s>
a
(3
T3
O
X
-S>
a
d
CO
"a
be
rt
rt
a
<3
*3
O
a
S
a,
o
CO
5^
2
a
rt
X
cu
O
<3
33
o
G3
rt
33 hh
2 o
5
'3
be
a>
Form C.
Communfomlt^ of lltassar^ttsetts*
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name, Sex, Color,
'^L of Death/ 22mc /TTTO^ Age, £C
Years, / Months, .^^^JDays.
Maiden Name, ) If 1 '■%
Husband’s Name,
■foiggfe, Married, AVrdow-ed ur Diruicr^h
•Residence, j ^"Ut S® i_ ^
Place of Birth,
•Place of Death,
Name and Birthplace of Father,. /?^6d/VyUl4L f?
Maiden Name and Birthplace of Mother, / ytUCSlsif
Place of Interment/, (Give name of Cemetery),
-... of Undertaker. I Tu&u
s^lFILL OUT WIJ+Jr^lNIfr. ALL NAMES TO BE IN FULL.)
v?art£i%> £MaJ£
j^j^/
Dated at
on ,J
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,
Disease or Cause j ^r^mar> >
of Death, t Secondary,
died at
CtflA/C/wvvrv/v^
Age, / M ]£... D.
190 .
Duration,
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence '
of
Certifying Physician.
1
\ 0 . Jo • jfrforf',
r~ m. d.
£ki
k
a
) .
Date of Certificate, Aft r\J Ak 1900.
* Give also street and number, if any. f Give 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 the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
Section 5. Penalty for violation not exceeding fifty dollars.
Form C.
J~i
Commonlrroll^ nf lltasarlpsetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name, £JL.~ Sex,
Date of De£th, — &Z 190 0; Age, Sc Years, ("IN Months, (3s^Days.
I..) p.
x, ^HZ......Co\or,
Maiden Name, |K”J^j^wedj
Husband’s Name,
tglr, Married, Widen?*1 d or Divorced, ..Occupation, JSj d,/Vi Bilt.
•Residence, J f^n"; | /7^v£... ^ (flQJLs/
Place of Birth, ilS P Y'kiS'&tcA ^2l/L(Jy^
•Place of Death, A-wl-iV-'. SB..hlmA: __
Name and Birthplace of Father, (X.t.ljxPU'X. (t £ Yf <v
Maiden Name and Birthplace of Mother, fyjrt t&CL^ y/\ t ^ jdA, ^ %LmJX4Sl <CM v
Place of Interment, (Give name of Cemetery), £~
Dated at Signature and
V sy (ft place of business
Oil / L2.12:iddAS.AA- y .S 190 O of Undertaker.
cmJLm/l. 0 / )
" L r>
Ui'lWUSv $73
IS
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! *sL> i nXQ ,. ,FHr^ <ll~ ’ Age, $° Y. - M - D.
Place and Date of Death, ' died at 2^ L<^uf 190 <?.
Duration, ZL
2^.... Duration, S~
Disease or Cause i ^ 1'imar3' *
of Death,! ) Secondaryj
*\2cr{ by-**/''
f. / /
I certify that the above is true to the best of my knowledge and belief. /
’ I .V‘^ u , M. D.
Signature and Residence ‘
of
Certifying Physician. ,
C , r7//AiffI>,
Date of Certificate, ... v CT?? Jff 190^.
* Give also street and number, if any. | Give sex of infant not named. If still-born, so state.
I If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
1
o
i
o
cs
Q
T3
3
a
43
rt ~ ■ 4
-P
O
-P
£
A b
rt
-rt
a>
-rt
-*r
•*?
rt
G>
rt4
o
rt
o
nS
rt
O
-O
H
O
<
P
H
X
w
3
O
-3
O
fcD o
b -a
Ci -*J
43
a o
o
£
a
O 'O
2 a
£» a
W n
la «s
H
Q
w
C/3
>>
a
a
a
5 *
o
a
co
.3 3
a
a
fcD
>. -a
a o
a rs
43 —
o
a
"a
2
3
a
a
'C
a
43
a
o
o a
* if
V. 3
a
a
43
#- 'W
o
a 41
43
a a -j
£ r, •;
a
>
'Sc
_a
Tc
o
42
■J, a
cc
a
01 “
£ --
bC a
— a o
%-i
ej
O
o
<s
o
a
4-3
M
o
-rt
4^>
rt
CD
C4-4
#
•
P
-4-J
rt
<4-4
O
O
;
1 — 1
n
o
CO
o
ns
-rt
-rt
rt
O
i~>
rt
3
o
d
C3
CO
1-H
a
rt-
-rt
"3
rH
c
4-3
CO
a;
o
13
<v
4-9
o
-rt
--j
CO
H
O
£
a
o
4-9
*— i
O
.2 ^
> t- ,
o a
2 4!
43
a
43 a —
>>
3
43
—3
'5
43
&
rS
a
a
43
a
cr
a
^ 43 a a
03 ,4
a a
> O
fcD
a
O «-
P
nS
fcD
a
a
-rt
CO
a
3
£
.5
3
*s
p-
rt
ns
rt
rt
£
s
o -p
a>
o
sa
<y
fcD o
co
rt
rrt
rt r-
rt
-rt
O
>)
44)
'3
fcD
a
•r- rt
fcD o
fcD
a
rt-
◄
T3
o
o
o
n
<*-4
s
-rt
4J
o
CO
<D
<u
*3
CO
44)
u
rt
.2
s
O
rt
^3
a;
4-T
KH
s
a
&.
4 <»
3
CT1
(N a -a
S ’C M
o
>>
in w
a
a
o
a
>> 5
O. -a
a
o
41
a
C.
a
43
a
43
“ 03
ri ^3
rt rt
o
rs g
3
o
M
a
rt C3
ns o
rt -rt
rt ^
«^4
P
a>
a
-rt
--9
o
ns
<D
o
CO
o
44)
o
o
-4-9
TS
a
fcD
u>
H
P
a
rt
<D
|
rt
O
4— >
o
o
o
o
CO
O
3
2
CO
44)
H
a>
-p
O
tH
T3
<D
n
P
P
4-9
rt
t-
rt
ns
<y
-rt
rt
£ _o •
O ^ .rt
b rt
O ^3
rt
fcD
co
>>
."b 4,3
*3 *2
rt 5
-rt
o
rt
rt rrt
H
M
W
o
-rt
o
£
rt
O
crt
O
>> -3
ns
o
rrt
fcD
rt
a ^ —
£
rt
-rt
-rt
H O J H
H
Q
w
02
w W rt
O 0) g
-rt -rt PG
bD
a>
[Form No. 37.]
Permit JV'o.
Ju
RETURN OF DEATH.
Year, .
Bate of death j Month.— T Birth
Day,
Year, Sf'2'S.. Years, 77-,
Mon th , Months, v:
Name in fuNF^fP^/^^Sd^ IMP- e.
Maiden name,
f Sfugtr.
Bay, s 2- — . ... I Days,
_ »
Beside nee, i /Py
Sex
Male.
Conjugal condition <{
Married. -
Widowed.
Dioorvtdr. •
Color
( White.
Black (lAV/nt or mi>.ved), -
Indiarr.
Ghinooe.
thapint eso.'
Wjriow of.
( Female.
Wife of
Place of death \ ^ eei’ [
Place of birth.
Occupation . ...
Name of Father, 7^ .
Birthplace of Father , ^
Place of interment,
Undertaker .
PHYSICIAN’S CERTIFICATE- QJ^FHE CAUSE OF D€ATH.
190 0..
Oden Name of Mother,
Birthpla^ce of Mother,
Name and ' age of decech^ / <*_
Bate and place of death ’/•? ^ "7, , ,
( Chief cause, il ,
Disease , <J
Buration
( Contributing cause, ^
j Chief cause,...
{ Contributing cause,.
I certify that the above is true, to the best of my knowledge and belief.
C~\ ) A i
Is JbUb <fl m.b
Name and residence )
of physician , J
*ff in an institution, state how long an inmate and previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows: — Saturdays, 9 A M. till I P.M. except during the months of June,
July, August and September, when the office will be closed on Saturdays at 12 M ; Sundays. 10 A M till 12 M Holidays, from 10 A.M till 12 M.; other
days, from 9 A.M. till 5 P.M.
*** '
. .. rvSt; '-T1
Form G.
vo. A ZlL
Commontoealtfe oi lltassaxbusetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH IJJK. ALL NAMES /fO BE IN FULL.)
Name, Q
Date of Death, /O
Maiden Name, j If m^fvir^d?wed
Husband’s Name,— —
Cj $0M[fMJ~-Siisi,JL. Color,'
'AMJjddk i5H-.iL. ... 190 ^ ; Age, V. Years, Months, ^ Days.
-Single,- Married, AVt-1ou;iihI ■ m Iti-rmmiT O^Gupaiitm*.
^ If out of town,
xve* laeute, J also state fully.
Place of Birth, //
•Place of Death, ./J. —
Name and Birthplace of Father, Sj/ / 5 4' id P Q /pytA
Maiden Name and Birthplace of Mother,
Place of Interment, (Give name of Cemetery)
Dated at ......
A0/?jU*vUv t(5~5l 190 G
on
Signature and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,
— . „ ( Primary, I - Duration,
Disease or Cause J J
ot Death,! j Secondary, j Duration,
I certify that the above is true to the best of my "knowledge and belief.
Signature and Residence
of
Certifying Physician.
Date of Certificate, jAJJjU^UAaJLls^. 5>. 190 O,
* Give also street and number, if any. f Give sex of infant not named. If still-born, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
2 Wrdkl. Age, Y M 1).
died at yy (4lA HyVIa/o AOjLe£AMJrK£^£.. Z 190 C.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
O
CP
o
d
G
33
V
05
d
>
c3
^3
0)
•
12
ns
«3
aa
as
a
rt
0)
•«p
•*p
c5
c5
CO
e3 to
o
3
<J
«*-l
O
>> |
3 o
aa
<4P>
§>
Ij
aa
S 'O
aa
o
h
c3
a:
3
CO
<^9
oS
0)
‘C a
&4
o
a>
"3
V
d
aS
O
*3
o
-a
o
00
d
a
33
o
cu
05
05
15
£
H
O
<
05
-a
M ^ ^
eS
o
ra
◄
c
O
d
05
33
a
o
aa
H
O
-sj
a
H
K
K
a
o
aa
O
aa
s*
«
^3
'C
a
>
W
o a
H
O
K
OJ
>1
a
cS
o!
<v
T3
.5 3
CJ
■a
o
o
33
►> “
'S ►»
2
V
>
s
as
—
d
C3
'm ■
t-
0
a
3
o
^2
a -g
Cj Ui
05
as
o o
«- *c
O
>>
‘3
Z d
•p ^ ^3
to
-a
d
3
c
o
d a
>->
a
a
.5
la
05
aa
05
05
aa
ad
o co
>> TS ^
as*
(-1
-2
"3
a -a
- £
* S a
2 33
05
aa
o =
o
>>
o
00
o
as
o -2
aa 05 05
a a
a rr- £3
T3
a
DJ
-*-3
O
fl
o
S
S
3
a>
bD
O
QJ
a
05
.2
*3
bD
3
>
’5b
o
O
*3
cr
3
05 3
05
aa
t''-
CO
O 05 05
aa
o
os
aa
aa °
aa
<y
-a
33
a
d
O
a
3
£ -r
d S
d
>>
a
bJ)
£ 33
a)
>> 'C
O
o a
o
bfi
o
Po
O +2
a
aa
d
aa
o
H
O
*<
3
H
M
K
o .td
3 *
£
+3 ,
CO
bfl
a
bD
o3
bD cj
v a
a* 05
„ 33
b£)
a
d
aa
CD
3 .2
C3 • —
d
aa
s a 2 § a ■: -3
o
fl
a
a;
bO
d
o
«*-«
>>
05
-a
2
*2 ^
• „ r/)
rt
oa
S
ti ci
05
as
a
a
Ut
05
Cu
’3
*5
CO .fl
P^> 3
05
co
a
•+j
« g
a
O
u
>>
aa ^
£« ,2
OS
05
.rt
'S
£* ®
o
05
■< «
3
hH
05
6
rt
or
o
32
d
o
3
d
0
rO
05
aa
co
a
cr
2^22
H
b
a
c/2
C/2 C£
O
5
co
H
O
a
co
3
a;
c3
O
aa
o
aa
o
aa
rQ aa
b£>
<D
Form G.
Xo.
6V-
(Kammrmtedtfj of IJlassaxfcusetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
WITH INK. ALL
Name,
Date of Death,
Maiden Name, |Ifm“^-r^wed
/
Husband’s Name,
FULL.) _
^7
ALL/^?AM£3fTO BE IN
* Sex//Z«4C,..Color,
— 190 Age ^7^ Years, ' Months, — rr.Days.
Ct — _
x
Single, Married, "Widowed or Di^reed,5 / /£<^1!<5<£^w()eeupation,
•Residence, \ | _ ~ _ fjtjttd.
Place of Birth,
•Place of Death, ^r/wwMMnc, . ml
Name and Birthplace of Father,
Maiden Name and Birthplace of Mother,
D.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, t V* "* A ge,$~P Y. _M.
died at.. *p}uA* <L^<3. / & 90 a .
Duration,
Duration,
Place and Date of Death,
Disease or Cause j PrimaT’
of DeatM ) Secondary,
4.
I certify that the above is true to the best of my knowledge and belief
KllOV
* Give also street and number, if aDy. f Give sex of infant not named. If still-born, so state.
J If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
a
O
o
u>
E
•
^2
rE
pE
V
-4J
<*->
4-3
E
E
e:
*3
pE
E
*3
CO
fl
E
CO
■—
<—
o
E
o
<P-3
E
r^»
-2
o
s
CO
p*>
E
E
E
pE
•4-3
2
E
t£
V-
E
-E
"o
E
CO
O
-E
<4-3
E
E
E
a
p-
'o
T3
fl
E
-4-3
o
>
E
t-4
rO
pE
CE
3
2
E
jj
E
*-
-4-3
fl
E
E
pE
+3
-4-3
E
E
E
3
E
CO
4->
Td
■4J
fl
ns
5
E
>•
E
E
"t-i
S-I
E
. -4-3
4-3
o
rE
E
fl
_T O
c3
-E
CO
M -
E
o
Ci
Ci
cc
b
O
<
E
e
rC
c5 ,2
-E
£
E
g 8
e °
C- r->
<
fl
o
£
b
O
<
fl
b
u
T3
a
o
pE
o
pE
a
e
EJ
E
O
e
E
T5
• *%
O
.2 3
05
4-» r*
pE »— »
O
e co
> rt
E -E
2 S
• o
a
o
‘■5
y
y
<n
>>
^2
tc 5 1
y
.a
>>
P3
T5
y
3
tr
a ^
g 3 5
ii ®
2 e5
“ *“ •§
E
E
pE
l> __
2
‘3
pE
a
bD
pE
E
Sh fl
j_ e
o s
fl
• —
c
E
pE
or
E
tM
E
as
E
E
E
®
E
CE
<4-1
O
4-S>
E
E
E
G
u
E
-4-3
E
£
<4-4
E
pE
-4-3
fl
G
E
-4-3
E
-4-3
CO
rr
c
E
2 ^
^ *3
e
-fl
1-4
-2
"3
a?
-E
E
-E
E E ^ O
£ e fl ^
E
cr
o
E
E
E
PH
-
.fl fc
e
E
bD
O
° E
8 ^
’-2 E
O O
3 2
o 2
> o
Tn O
e
pE
to e3 -E E
4-3
E
E
bD
43>
o
• P4
E
4-3
E
S-4
4-3
E
a
E
durin
<4-4
bD
fl
servei
4-3
CO
fl
E
CO
E
4-3
‘2
fl
E
O _
-3 -E H
-E E
co E -E
.E
— -E
E e3
E ^ O
.2 S ^
.§ e %
;e s- e
E E 'C
E
pE
-pJ
-E
E
"p3
o
oo
a
o
co
b
◄
CO
-g e
E E3 -fl
o
2
e
e
2
E
CO
E
pE
E O
fl
a
B
= £
O
CO
c/>
14
4-3
fl
o
E
-fl
fl
E
4-3
E
£3
S-4
o
E
-fl
E
t p
E
C
CE
e
pE
£ O ^ E4
£ fl .5
O a E
P E fl
£4 r/> 5
o
y
*5 o
o
>>
t. -3
<2 .3
33 ’
-3. O
. a
o «
_T r-"'
^ to
— „
be
_c
a
cS
- a
a
o
y
y
33
Fh
bD
rt
33
O
33
£
a
cl
bD
y r3
o
y
bD
u
rt
33
y
bD
a
t*> sr>
*-* . — :
•a ^
a ^
V <J
cr* ^
G)
>1 E
.-t2 H
O X
fli w
o
a .ti
5 ^
° o
o u~'
E E3
a e
CE E3
CO *-
O
>* -5
1 1
&4
o
tD
E
E fc- E
tr.
E
fl
4_>
S-4
%
Sectioi
fl
E
CO
<4-4
O
o
H
Q
—
E
E
pE
o
H
O
a
o
H
E
a
fl
O
o
H
-
a
<4-4
O
E
4-3
rfl
E
<4-1
o
C/2
C/2
fl
cc
E
O
T5
E
O
E
a
E-
<D
E3
,2 o
vu
O 53
a
jo
E <4-1
E O
*.§ -a
aj u
>> 2
33 O
a. as
o
sz;
!5
O
H
O
a
co
>> a
a. o
3!
cJ
y
3 33
33
y
33
y
33
a a a
y y 2
y y °
33 33 PS
2
"bb
Section 5. Penalty for violation not exceeding fifty dollars.
Form G.
Cflmmonfojealtk flf lJlassaf|rusetts.
Vo. ’'d &
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WlT/t^ INK. ALL NAMES TO BE IN FULL.)
Name, AtlSkl... Sex,/fe.*d££ Color,
Date of Death, d..CA PjstA. I Aal/. jlJL 190 0 ; Age, Years, ( Months, f^r.Days.
Maiden Name, j If m^fvd^?wed j
Husband’s Natricy:
Single, jHamud) Widuurrt uyDivoiucd, Ocoupation,
•Residence,
Place of Birth, St /./ a.......... S../..
•Place of Death, _jLL
Name and Birthplace of Father, $.<?..
Maiden Name and Birthplace of Mother, A>.asi a A-
o. Qhevltea* Co iZaJ/ia
' < fj A ^
Place of Interment, (Oive name of Cemetery
Dated at (SjBa
PQAMsCt
on
t-A..a 4.2 Signature and
_ place of business
Ar. c-?. 190 C of Undertaker.
rj
j£)..UMdsnM.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,
Disease or Cause I ^>r"11,lCv >
of Death,! j Secondary,
d) Age, Y. M. D.
r ,a y/& /) r ) ?)
>/ 'Jfc
died at
190 0.
Duration, ...
Duration,
1 certify that the above is true to the best of my knowledge and belief.
Signature and Residence 1
of
Certifying Physician. ,
M. D.
Date of Certificate,
190 .
* Give also street and number, if any. f Give sex of infant not named. If still-born, so state.
| If a Soldier or Sailor in tlie War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
i
©
Ci
"es
o
o
Ci
T3
05
o
ei
C5
'C
ci
'C
J3
O
-a
-
.a
e
15
05
00
sS
05
H3
H
05
◄
T3
O
05
a
a
K
H
c-
•«<
ts
O
03
05
T5
c3
O
H
O
CO
H
K
K
3
O
33
bD 05
b 33
O
31
03
'C
o
-a
ts
a
a?
>
K
d
03
75
d
a>
7:
tj
'5
75
a
d
.5 3
d
03 CD 03 ^
k d 4 O
rf 43 ^
0)
bD
d
43
03
>> .5
5 3
£ ^
33
o
3= *
cO
<u
«-
C.
C3
33
r.
3=
05
33
>>
'O
o
>>
32
05
rC
33
w
O
0
Ul
d
00
d
03
d
*u>
43
0
0
C/3
|H
CO
u.
cn
0
73
-*-»
*5
>»
-f3
*3
0
S
a.
p^i
a
^3
C/3
CD
<13
03
>
C3
43
+3
U
O
Ui
o ’bD
t
Ui
03
42
*0 — 1
0) c;
75
«
43
3
cr
a)
£ ®3
*- r-»
03
A-
bD c$
•js a c
4*
u.
-2
"3
,2 *■<
a>
42
03
03 43
75
e
ci
0
O
33
d
d
*00
w
0
d
4d
u
03
ci
d
03
33
05
3
CD
C/3
CD
CD
03
u-
73
0
'S
cs
a
a
u.
03
43
- £
fc-
a
00
a>
43
13
-u>
43
-u>
d
a
O
-u>
u-t
0
43
^d
•'“*
Ul
03
03
d
0
O
£
.2
43
O
a
0
"d
-u>
d
e
-u>
CD
03
^3
03
*>
a
0
cr
03
u.
03
4=
a?
bD
o
03 43
•S — 43
4= fl
d
o
7S
H
03
<
bD
a
_ • o
*d "3
•3 .fl
a>
43
t-
CO
03
43
O
43
>
O
£
d
03
Cfl
w
K
<
G
o
£ 'C
_05
j§
o
>> 05
3; O
03
0
-u>
d
O
>> u
’ 4 ^
d
d
fl
C
‘5
d
%-i
U-l
-*->
3d ^
a s
fl
CD
d
CD
d
03
bD
03
d
0
OQ
u
03
O
03
03
43
-u»
O
Ui
03
03
s
O
>>
u>
*3
O d
03
O d
^ 43
.2
d
u
<u>
2
rd
03
CD
43
■u>
d
03
u
d
43
03
bD
03
fl
d
73
•—
O
31.
03
0
03
-u>
C3 O
*bb
d
03
<4-1
fl
03
O
2
.2
bD
43
*U>
0)
Trt t?
03
03
03
O
>
d
d
o
h
05
<<
X
H
X
w
o a a o
05 33
05 3
05
33
Ul
05
33
to
C^.
33
U
33
to
a
o
to
Si
05
CU
45
3=
3 U ®
Vj «
< X
fl
<N
0
03
fl
*3
P5
Ui
O
>>
CD
O
*d
O
O
d
0
H
03
a
d
«4-l
O
H
O
03
43
H
03
4
H
03
0
a*
H
03
W
CO
u-i
O
03
d
73
03
Ui
c 7i
u
O
73
03
a
in
O
d
a>
43
d
75
c
o
o
2 .2 75
CCf
43 73
5>> g
•§. £
ci
0^
'C
o3
O
43
o?
43
O
43
a
43
*-• d r-
a
d
d
o
73
bp
*co
o
d 43
O ,t3
3
43
d
43
d
«3
>>
£
32
a
05
33
H
05
w
0O
u
03
03
-u>
fl
03
CD
bD
"fl
d
d
u
12
O
‘S
v
4a
d
d
O
43
03
43
43
-U>
A
73
d
03
03
43
CD
a
’fl
%—
u
0
<4-4
T3
d
03
03
u
cS
O
43
«
bC
fl
"33
05
05
C3
05
oS
a
0)
Oi
S
u
75
£
‘5b
1 »' >
/ -
• 'Form O.
®ommonfomIt^ of IJtassarfrnsetts.
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Ud,
(FILL OUT WITH INK. ALJ- NAMES TO BE IN FULL.)
kXt
0/r
narried, widowed j
or divorced. i
Name, v- - 1 \ Sex, . ../..hL/.. Color,
Date of Death. l ±A//f, ^ f- /./ .190 f ; Age, x~$ Years, /. Months, ..Days.
Maiden Name,
Husband’s Name,.
Single, Married, -Widowed or Divorced, ^ Occupation,
•Residence, j JSS^; j ... :
Place of Birth, (/
•Place of Death, '
;/i flPJ), fljjooj )
Name and Birthplace of Father,
Maiden Name and Birthplace of Mother, 72*4/.
Place of Interment, (Give name of Cemetery), ...._
AAK r*c/
lcl sx-><luaa -
•
Dated at\ _V>C /Lhfh.
on oMciUdJMAhf.. 190 /-
£
Signature and l -y^-
place of business *
of Undertaker. I
Uhl f
y yptcuA-
PHYSICIAN’S CERTIFICATE.
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,
I 2
190
• Give also street and number, if any. f Give sex of infant not named. If still-born, so state.
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town
//
Agent of Board of Health.
RETURN OF THE DEATH
cj
J3
cl
C5
cc
CO
CJ ^
E 4?
H
O
-<
CJ
cn
a
IS
* I
_r o
aS
3:
15
n
as
o
as
&
o
aS
«
W
H
S-
<
K
O
3
a>
rs
H
o
c
es
H
K
K
s
o
-a
cj
O O
« ^
fcD CJ
b 33
C3
*3
o o
o
as
*
.2 «
o
'C
o .2
o
.a
be
t:
3
£* 2
a) '
H
O
«
CO
>>
c
3
«
-a
sj
o
r3
T3
'3
C J=
bB O
o
as
>>
5
E
c3
as
u
e!
o>
ns
<s
as
*3
c
o
as
s
#3
3
CJ
>
s
C
’5
cS
JZ
-*-»
t-H
O
0
a
CS
-«->
*~***
0
C3
-3
co
‘■5
CJ
OJ
OQ
'm
t-i
O
>>
0
—
CJ
>
>>
U-t
_n
t:
>>
CJ
CJ
CJ
0
CJ
'C
a
rf
'S
Ut
f3
■4^
cr
CJ
CJ
u
cc
g
*3
S
OQ
c5
CJ
3
cr
CJ
(-1
CJ
Qi
-♦->
e3
CJ
a
Ss
5
o
>>
-J
"3
v
as
bB 3
P->
a
3
o =:
2 *->
o as
cj .2
'C
a
3
«
as
^ c ^ .2
33 -<u *3
a
cr
o>
Sh
to
o
<u
as
3 — as
2
2
<u S
> o
•Eb O
a 8
bB
3
«
as
as •-
3
■3 ^
571 -
<D 3
<u
as
be r
£2 q;
•f? CO
CJ
CO
rt O
<3 52
cj
E
o
£ 'sS
<u
>> n
Z §
S S
O rt
o
s
o
CJ
33
bD oj
b cj
GO c5
bD
a
33 CJ ^ CJ
'•— * TV t>- *-<
'C
fl
C3
a
a
o
CJ
bn
3
^ t-> .3
0 0^2
>> s> s s
CJ
H
34
◄
rf
^ £
CJ
3
o*
2 c3 g
H
CJ
3
C/2
c/2 co
2 H
^ CJ
3 W
r. CO
a
t- ~
C/2
>>
33
c3 o
<g 3J
rTZ
a
o
33
CJ
3.
CJ
33
Ci
00
H
CJ
◄
CO
:i t
o
H
U
C
3
H
X
w
o
as
3
v
as
3
as
■3 gj
3
as
g T5
3
as
3
o
>>
*» •«
‘° a
3 ^
c
be
CO
-*-3
f3
3
CJ
0
0
CJ
u
O
*+->
.
-*->
c3
,
OJ
CJ
c3
r—>
CJ
C3
3
CS
n
’Xj
‘-*3
CO
o
>> -8
'3
O
as-
iy
be
3
3
as
c
£
o
■3
as as
,- 'O
H
3
X
CO
A
0
CJ
-*-3
CJ
co
c
c3
O
CJ
b
CJ
CJ
5
*
be
| Form No. 37.]
X
Permit No.
RETURN OF DEATH.
t]06TeN,
\
\
v
\
(
Year, /
Month XX'
Year, /<?*/.
Date of death j Month Birth
1 Day, z'.. >> t Bay,
Name in fujjpjyy^<iiay ^ff) ^ Pesidence,
Maiden name, W '
f Single.
Years,
Months,
Bays.
Sex
Female.
Conjugal condition
Wife of
.Harriet! .
Wirturnnh.
Biem'W.
Widow o
White.
Bhiek (Me§)'<J~t)r mixed)
Indian .
mest
Place of dea th j \er }
Place of birth,
f Occupation . c
Name of Father;
Birthplace of Fatly
Place of interm
'F/ N-i't't / l
Eastern
, Date aria place of death,* ..
Disease
j” Ch ief
cause,
f 4«,
7/3 jp/. /a?.
I
Maiden Name of Mot^leIF^4F7t^4s^+4^/&,
?MA*FBirthplace of Motheir^ X/^
U ndertaker .
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
My /J 190 / .
Name and age of deceasecfy /^^fZd^FFffy f
Contributing cause, *
\ Chief cause,... o^)
Duration. \ OO
'1
Contributing cause.
' ✓
I certify that the a,bove is true, to the best of my knowledge and belief.
i_ V-- ( 1^0- /' /ii)s /fe'ZTV'lM v.. M B.
Marne and residence )
of physician , '
* If in an institution, state how Ion# an inmate ami previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows: — Saturdays; 9 A M. till I P.M. except during the months of June
July, August and September, when the office will be closed on Saturdays at 12 M ; Sundays, 10 A M. till 12 M Holid»MAffom 10 A M till 12 M ; other
days, from 9 A.M, till 5 P.M. .
?7-£/
rYvo'vU=>
.’00-37-XXM.]
) 4 1
Permit No.
RETURN OF DEATH.
BOSTON.
Year,
Year,
Pate of death , Month, Birth j Month,
Day, / f/ v /j L Day,
Residen ce,
Name in full,
Maiden name,.
/
Years, ‘
Age i Months, ' /J
1 Days,.
irbr&fr~
Sex
Female.
Conjugal condition \
Married.
WidoTDed.
j White.
BlebcdcrgMegro or mixed).
Color ! Indian^
I f J t '?/ f t 1 s e,
Japanese-
Wife of
Widow of ^
Place of death { Member } {^ay ft f (Mao, CUfaaojl
Occupation. s c
Name of Father, ^^^<2/^COZ^y Maiden Name of Mother
Birthplace of Father, Bii'thplace of Mother, Aa-1 ct
Place of interment, (^PAAAf/.0mm^
Undertaker.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,
Name and age of deceased, S. /?c
Pate and place of death,* PA OiMg
j Chief cause, Nlfik.
190
Pisease
Puration
) Contributing cause,...
\ Chief cause
Age,. ^ yf years.^y^LYf
| Contributing
cause,
I certify that the above is true, to the best of my knowledge and belief.
Name and residence )
of physician,
MD.
lIf in an institution, state how long an inmate and previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows: — Saturdays, 9 A M. till I P.M., except during the months of June,
July, August and September, when the office will ba closed on Saturdays at 12 M. ; Sundays, 10 A M. till 12 M. ; Holidays, from 10 A.M. till 12 M. ; other
days, from 9 A.M. till 5 P.M.
L
oF*'
■n
.
1
Form C.
Commoniuealllj af IJlassacfrusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT/WITH INK. ALL NAMES TO BE IN FULL.)
Sex,. £ Color, A __
n=S..<5._ ; Age, Ja.U ..Years, ..Months, CSr;._Days.
!0mdJjoL
T
Date of Death,
Maiden NameS j n nw7^;,";^|°":ed
Husband’s Name, — VlA.(AA.
-JgJJ
Married, "Widowed tip Divorced,
•Residence, j ^"‘tafe & ( Q^&k
Occupation, -
^__2 VL42L&&.
Place of Birth, * 7' r //' m ,
•Place of Death, ?2 f / <? Qd£l C^LJS. (7f_ (a ’At A/' ) AjOU VJPJl
Name and Birthplace of Father,
Maiden Name and Birthplace of Mother,
SdyCl - QT/jrfJfjL
Place of Interment, (Give name of cemetery), kAdJf L ' cf.QB f dHi. ..lA/l/£jNLN4.-
y J A f
. Signature and l ^ ^ 0U/VlAl7Ay CC
' ' place of business
OH ' of Undertaker.
UTUj
? ...^2Maw.a
Name and Age of Deceased,!
Place and Date of Death,
M.
D.
Disease or Cause j »
of Death,! Secondary,
PHYSICIAN’S CERTIFICATE.
&. Age, Y.
died at /b 190/ .
Duration,
Duration,
I certify that the above is true to the best of my knowledge and belief.
t A? > A NTzrz/iy^' — m. d.
' ?}'i ^ — s
Date of Certificate, iw .
Signature and Residence ‘
of
Certifying Physician. ,
* Give also street and number, if any. f Give 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 the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
Form C.
fiommonhiedt^ d !Jla$sax|wsetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
jy r (FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name, / A (■ ^ C 1 (J J.^JoiAJL. l.Cfcifl/Q.. cy\ ..Sex, Color,
IQAAAAA.AAA. : OA&f ; A ge,C^_ Years/^V Months, Days.
Date of Death,
A
Maiden Name! A* m^-r^»we<1 j
Husband’s Name,-..
Single, Mauied, WtllOwrd or Divorced, Occupation,
•Residence, ] ^utc fX.’ |
Place of Birth, J/]yA) ^ 0 ^CXty.OLOVl O 1A Ok £aAL fO P
•Place of Death, 2. J
Of SO
Name and Birthplace of Father,. Q^ULl ^ ^ ^ C^AklsP kOOk — Jy OfffJtAAA/3' 'fy/L&J
Maiden Name and Birthplace of Mother, OUrtk. $QaJjMj / QmaaLo^ -JudJSk.
Place of Interment, (Olve name of Cemetery), i 2“ .At/ QaOOOSO'
J? o
(Q^jnoc(y
o jo' yHo/aa
Dated ,at I
on \cidAdAJ2JAj... ^ 3L
* Signature and
v / place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! ■ 1 At-trCg /' ' 'A — Y. — M. D.
Place and Date of Death, died at ‘1 1 1 90 / .
// /""> ' // yf
r ( Primary, • ^.‘/^AkArr. Ijffffk' Ci^<du<l duration, C*.
Disease or Cause ) J f
of Death,! Secondary, (, i.-<— Duration, 3aL^, r..._
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
of
Certifying Physician.
ffl* — xAqsq
D.
Date of Certificate,
190/
/
Qz*
* Give also 6treet and number, if any. | Give sex of infant not named. If still-born, so state.
J If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Boutd of Health.
RETURN OF THE DEATH
Form 0.
ffiommoniuealtfe of lllassax^wsetls.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Husband’s Name,—
Qlnnrlo Aimr-lo/I Wirinwrxl f| [• | > 1 -Q,l " OcfJUpt>t jpU ,
•Residence, j H?.’ ( ......
Place of Birth, Ao/UdA Od&yiAA*-^
sr
s>
•Place of Death, 'L ^
Name and Birthplace of Father, _ .{o olwpLMb J&, fee A) a , vTntAAA ■ (OV .
Maiden Name and Birthplace of Mother, ft 'flfJ.A’JB QJjf < Cfegr~6zW A/Louia
Place of Interment, (Give name of Cemetery),
/r
Dated ,,at
or
0>
,jiD.u/L/yyi'Wyu £ 7%lOfJ2L-
r> j{ . . place of business -l K (C#
QA^I/IA^ZAAJ^ O.../... ' -190 / of Undertaker. [ _ __
Signature and
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! ^ Age,-
Place and Date of Death, died at tffl
Disease or Cause \ Primar-V’
of Death,! ) Secondary,
I certify that the above is true to the best of my knowledge and belief.
,
Signature and Residence '
of
Certifying Physician. ,
r y /
Date of Certificate, /- 190/
* Give also street and number, if any. f Give sex of infant not named. If still-born, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
M. D.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
*+ aa
cp T3
£ 03
GO
ci
a3
CP
cp
: *
3 .2
_r o
oJ
.a
a>
-a
_a
o
_a
£
a
o
-a
o
as
fe
.2 "
a
-a
o
aa
CP
•
r0
a
aa
-4-3
aa
4-3
Ci
’3
CO
a
Ci
CO
*5
4-3
o
4->
CP
Td
<4-1
>>
3
aa
o
CP
bfl
O
3
o
,
CP
aa
2
"3
3
»-
ci
a
CO
43
oS
*U
a
3
dd
CP
cu
CP
CP
J-l
CP
HD
CP
43
>>
CO
<+4
Lhc
4-T
o
3
ci
43
cp
CP
►>
-a
a
T3 .2
a •-
3 s
CO
cj
43
<4-4
ci
aa
O
CP
>
‘Sb
a3
ci
3
cr
cp
cp
Cu
£
dd
«g ca
X *H
CP
o a
o
aa
-^>
ci
CD
T3
a
ci
CP
3 ^
OP
-a
Td
CP
^ a
d
a 2
o aa
o
OP
*5 CP
a
cr*
CP
CP
to
o
CP
aa
dd X3
a3
43
ci
CP
"3
health
o
a
CP
>
*-4
o
a
a
O
a
CP
a
CP
uring
4->
O
<fH
bp
r3
CP
>
CP
4-3
c3
4-3
CO
CO
CP
4-3
<4-1
O
‘5b
O
CP
&
CD
'C
a
t*3
43
CP
CP
CO
0
a
cS
CP
3
V
3
a3
a3
-3
CP
o
CO
*4
CO
CP
%
CP
ad
CP
u,
CP
3
CO
a
aa
CP
•4-3
CO
rt
a
o
■4-3
dd
c3
t-,
a
aa
CP
aa
CP
CO
CO
CP
aa
4-3
*5
a3
4-3
ci
CP
ca
*as
(-4
.2
3
ir*
S-H
<4-4
CP
ad
CP
aa
2 t
bo
o
a
o
rt
aa
c3
aa
o
be
a
be
be <u
be
a
a o
>
ci
aa
^ ._, .2
aa
43
ci
ci u
a
o
aa
CP
a.
c?
aa
O CO CJ
> 03 £Z
cs a ^
C3
a
CP
cu
r*
O
a
4-3
fc
c3
rT3
CP
3
s>>
—4
aa
CP
>
o
ad
>>
CP
CP
-3
u-
'C
‘3
a
CP
u.
CP
CP
a
aa
(h
CO
CJ
4-3
4.3
<4-1
c3
c3
o
4-T
CP
ca
a^
a
d3
u.
CJ
u
CP
a
o
3
T3 CP
a -a
ci ^
t>
o
00
CP
X3
'S o
a +3
CP
E 2
cp a
a
CO
Td _
CO
H
OP
<1
a
CP
aa
t»
CO
'O
. a
-a ci
ci
CP
T3
a
fcD
*2 o
W
OP
CP
aS S
* u
O
►> 5
1 1
bo
ej
o
&*
•ra
CJ
t-i
a
‘So
aa'
43
a
a
o
CP
CP
3
CP
aa
<4-4
£*~s
4-3
3
'w
p-
furnisl
CP
CO
ci
CP
a
43)
.rt
3
l-t
CP
CU
>>
p
ci
a
CP
4->
aa
4-3
o
43
ci
s
D
S
>
00
3
ci
CP
ci
CP
aa
H
43
o
43
a
OP
Ph
43
CO
CP
a
HH
CJ
a
a
ci
CP
ca
43
S-i
O
aa
43
O
55
<o
fe:
o
<4-1
o
>3
aa
CP
a
CO
L^*
5?
O
o
aa
4->
*3
CO
5s?;
o
o
t-H
X
O
a
cr*
OP
5-4
a
o
i-y or
T— (
o
s
CP
JO
"a
3
CP
aa
<4-4
a
o
H
O
w
CO
a
<3
<4-4
O
<4-4 H
° p
« rg «
<u
aa
<4-4
O
H
CP
W
C/2
H
CP
H
C/2
o
H
Q
W
C/P
ci
"C
a
o
CP
H
b
a
C/P
ci
*S
3
o
Td
H
ci
S
H
O
W
CO
&.
O
P*~>
c5
as
cS
o
aa
'O
o
aa
aa -a
o <d
aa aa
os
nQ
s
a
.2
a
O
S
‘o
ci
a
t4
CP
43
CP S
w 2
a o
43
<4M
Vs
CP
o
CO
>
o
a
.2
ft.
Ci cp
CP ^
M
3
o
a
aa
43
CP
cp dd
'd
-a
U
CO
H
.2
a
CO
5 ^
0
0
O
CP
T
as
0
<5
a
o
<4-1 43
K
43
Oi
H
aa
° O
»
CP
.2 l
•s a
ci
O
PQ
bD
//
Form C.
Xo.
©ommoniuealtfr of lJtesax{j:ttsett8.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT /iWITH INK. ALL NAMES TO BE IN FULL.)
Name, A
Date of Death, .!*
Maiden Name, )Ifm^r^d?we
Husband’s Name,_ (l...
Sex, ...Color,
/A 'j_ 190/ ; Age, Years, ^^-rMonths, f\rdDays.
if
Vj /\ 07/Xa j
Single, Married, Widowed or Divorced,- Occupation
j ^ out of town, |
.Residence, j also state fully ^
Place of Birth, Xf) (fid AY M f
* Place of Death, .... / 0 MiAdML&hMjLz
Name and Birthplace of Father,
Maiden Name and Birthplace of Mother
\
Place of Interment, (Give name of Cemetery),..
(
Dated at
.fb
on
)ther, <f • cuaA < • .r/*.- •
/m place oi uusiues
_ _190 / of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! / / b, /X h > '< Age, / / Y.. M. I).
died
rp
Place and Date of Death,
Disease or Cause j Pr"mr-V' /
of Death, t Secondary,
w f ' ' /
at / 0 & ' f v 190/.
LA a* ' Duration,
Duration,
I certify that the above is true to the best of my knowledge and belief.
c ( y< /x < < y/< f /a ^ , m. d.
Signature and Residence \ ' ~A /) / X’/
°f ^ () /tS ([('I j r
Certifying Physician. /
6 - /AU-1-. 1 90/.
Date of Certificate, xL.X
• Give also street and number, if any. f Give sex of infant not named. If still-born, so state.
I If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
'Bqard of Health.
return of the death
4) CD 01 is
> eJ ja O
cS JO •»
- tS
2 —
0)
.a
o a
it
-o 2
>1
.O
'O
o>
l-l
’3
cr
■-
o
>>
‘3
<y
ja
o>
Cu
C' CD
I g
g °
S .m
-•- u
£ JJ
« o
'C 01
C -9
rt **
D
-5 01
^3 *2 E
<y
> o
o 3 3
2 ^
cl
<W
*o
a?
a
c3
CD
«
^3
T3
a
aS
a
bD
*2 o
a
j3
o
3
CD
O
K
<D
Cl
^3
'C
O
a
cl
a
3
^3
• cl
CD O
oj c:
O
*> -f?
a,
o
<u
3
a .«
cS
.fl
01
a
01
bD
eJ
c3
O
&
ai
-3
1
1
Form 0.
ffiammoitixr^alll] nf Utassax^setts.
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Husband’s Name,_..
Single, Married, Widowed . or— Divorced-, . ^ ^
•Residence, ) ILo^tafe TuUy’l
Place of Birth, f (Xa^is $aiA (?.... ......
•Place of Death, /j,
Name and Birthplace of Father, (o r *c/ Cftsff SljLt/
Maiden Name and Birthplace of Mother, LfA/istPJ!.. 7 P { ,^/^y: i >
Place of Interment, (Give name of Cemetery),_...^^/r..^^Z«r^^^L^^?
I)ate<Bat Signature and i ^ I'M 4CJ.
place of business < r/ / l //) A
190 / of Undertaker. ^ / Jf.. PP
on-
PHYSICIAN’S CERTIFICATE, / ,4^.
^ X/ X7.V Vs> /> p* X® uZEPPiri*^
Name and Age of Deceased,! '• 'Y 4441^ 44. (_ * 'CLi Age. ' Y. S M. A H
IhsJB. SjzJ 190 /
Duration,
Duration,
Place and Date of Death, died at C- 4
' Primary,
Secondary,
Disease or Cause
of Death,!
I certify that the above is true to the best of my knowledge and belief.
PA
■A
Date of Certificate, — £L...3 190/,
Signature and Residence \ ”
of
Certifying Physician.
M. D.
• Give also street and number, if any. f Give sex of infant i^>t trained. If still-born, so stnte.
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
/
Form C.
2Vo.
®ommonfom!tfe[ of IJtesarlwsetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Kflr , .
1
Qm‘ ^
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, t | /if • . . . Age, f Y. ^ D.
died 190
” - ^
Duration ,
Duration,
Place and Date of Death,
Disease or Cause j ■^>r^ruar.V »
of Death, t Secondary,
1 certify that the above is true to the best of my knowledge and belief.
/ (2 a. c y / Sr / c
Signature and Residence V «
°£ <
Certifying Physician. /
>C ^
M. D.
VU4i/ ,
, S2£~£L. 190 >;
Date of Certificate
* Give also street and number, if any. | Give sex of infant not named. If still-born, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of
RETURN OF THE DEATH
dtammontaltfe af llfesadpsetts.
No.
\
\
\
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name,
Date of Death,
Maiden Name, j If j f
Husband’s Name, ^ f.Z. -A —
Ua / - .
Sex, Tvo Color, Sr
; Age, Years, C Months, Days.
S'
-Single, Mtw-riedj Widowed or Divorced^ Occupation,
* Residence, | fun^K
Place of Birth, ^ I)JihcLyzdj.,
* Place of Death, ./(P & 2 t‘2cY, Y</(M
Name of Father, _
Birthplace of Father,
Maiden name of Mother,
Birthplace of Mother,-
Place of Interment, (Give name of Cemetery)
yi/iCL&2-j
Dated at
on
/i)
d<Lj
Signature and
place of business
of Undertaker.
r'.J r
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,!
Disease or Cause of Death, §
Duration of sickness,
€.
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence V
of <
Certifying Physician. /
M. D.
Date of Certificate, .. ,^7< ./Jjt.rf 189 .
Give also street and number, if any.
f Or sex of infant not named. If still-born, so state. t If child died immediately after birth, so state.
§ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
*ts
return of the death
Form C.
®ammoniu,ea:It(j of Jllassax{jitsetts.
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name
Date of Death,
£
7t
, (XJdtbJiii Sex, 47. Color,
of Death, y ^ f ; Age, 4/ Years, Months, & Days.
Maiden Name, | If m^^wed | (2A^(J^. lUXjJU^
Single, Married, Widowed or Divorced, Occupation,
•Residence, j ”2“**
Place of Birth, f (yy 'i
•Place of Death, >. /
vT ^ c ^ fjd-p ~y
Name and Birthplace of Father,— 3f C&dCA-VVt - f', /2
Maiden Name and Birthplace of Mother, 4j? r ^ CH/!/&l7 ~
Place of Interment, (Oive name of Cemetery), —
c ^ <1
Dated at Signature and ( i^..A/)/lAA.4A^ v.
/.^L. '?... 1 90/ Pof Undertaker. /[ (y/U/l/lyy '/y>
on
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! Jh Age, V / Y. ''“Srr-M. $ D
died at / 5" ? tvAw'lri^h vt' . VX /J,
Place and Date of Death,
Disease or Cause ( ^>r*Inar.v ’
°f Death’t ) Secondary,
.
1907 .
Duration, j {A&*-4rQ
Duration, / 3- o
I certify that the above is true to the best of my knowledge and belief.
Pw, M. D.
Si. Uwi^ ^ i
Signature and Residence '
of
Certifying Physician. ,
Date of Certificate,
190/ .
* Give also street and number, if any. f Give sex of infant not named. If still-born, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
_ yyia>v / 'jl
Agent of Board of Health.
RETURN OF THE DEATH
i
©
•£3
co
>>
ci
03
33
„ 33
03 o
i? °
? &
_r o
P, a
a
IS
i—
o
00
rt O
§ ^
J-
c5 *
03
03
H
03
◄
4-3
CO
-S 1
O a
o
33
cs
w
H
3
<
C
o
Cv
0)
nr
c3
O
33
bD o
H
03
-*
3
H
X
K
3
o
33
o
33
£
^ 3=
a
*c
o
o
33
j-i
K
c5
03
nr
H
©
UJ
CO
2 ^
'S
'S
~
a
o!
.2 2
05
as 03 y
> a jz
a ^ a
o ,2
y J3
be y
o
x
c5 O
e ^
- &
cs a
c5
X
W
«
.3
'V
o
,Q
>>
32
— >»
O
rz
tc
'S
= 03
^ rt s-
3
cr
o
bD
►
-a
^30
a
a
o 33
2 nT c3
33
03
33
03
33
2
c
•—
•p
cr
<D
4-3
o
33
s
(4
a
•*4>
trf
03
4->
*+~4
V
e£
cS
O
cu
4^
o
«n
M
c3
fl
V3
u
03
S-1
03
6
*•3
a
O
a
3
O
+J
rt
nr
c
03
3
T*
CO
rt
4-3
£
o
fc-
3
2
4-»
a
<y
o
44>
V
4J
3
03
£ c J3 .*-
Ci
00
3
cr
o;
bD
o
n ^ 33 <y 03
° r3 «>-i .« -c
y
c5
«
fe
a
2 °
c S
y S
> o
•Sb O
z x
T3
y
>
o
0
y
y
x
CO ,a
bD
3
3
nS
bD
c
o _
e3
-3
03
33
.9
3
a>
3,
£ 3
c3 R ^
^ c3
£ ns
03
>> "3
^3
03
4->
.3
"S s
»4 4->
3-. C3
03
n3
03
1-
CO
° .2
a ""
o ^
3
4-J
CO
33
4-3
Cfi
03 rr
4J rj
3
43
3
rt
*9 3
a
W
K
s J
o
03
C0
rt
'rt o
03 ^
t4
3 c
§ .2
«*-< 4-3
3
.9
3
6
o
>> ”
4-9 4J
y •§
* £
- &■
o
(11 fl)
3
3
ns
. a
33 ci
a
bD
*2 +2 o
o ~
-*4> 3S r—>
3 33
c5
33
03
bD
c3
33
O
>i
4J
’5
<y
H
03
<
3
H
X
W
33
0)
3
a .ta
3 *
3
32
03
w o
bD 5
3
O
33
£
£ O
cS 33
_ »rf '
O O ^3
O
H 2
03
CO
3
03
03
«*-4
bD
.5
O
o
o
4-3
<44
O
C3
33
co
03
03
nr
O
03
a
33
CS
3
r*
u
03
>>
ns
o
2
CO
3
3
• r-
'o
33
43
03
rt
O
3
O
CO
a
03
r3
ci
3
03
43
3
3
e
CO
r*
43
34
a
<y
bD
rt
cu
o
CO
.9
*3
>>
3
O
33
O
33 d
3- O
33
c5
O
33 33
e
<4-4
pg
t4
o
oo
O
&
03
Ui
O
<N
i-H
03
03
05
03
r-H
o
Sh
<44
49
any o
co
<4-4
o
X
o
H
O
33
43
n
03
o
H
O
fc
O
H
O
5-4
3
O
5s
o
p
y
S
rr
55
O
H
q
ician’s
33
<44
o
nr
55
O
H
03
w
03
>■
*03
03
CO
*3
5
03
S3
4
<4-4
o
^3
03
43
3
ns
03
cJo
<1-4
O
V
3
til
3
C/2
3
O
cc
o
o
03
CO
do
co
P->
M
03
o
33
CO
03
03
1-*
3
S4
3
<4-4
3
o
85
4-9
ci
03
ns
03
33
43
03
03
O
3
o
3>
CO
&4
03
3,
03
33
43
03
33
4-9
03
33
49
03
03
03
o>
rQ
O
M
33 ^
§5
^ r-
[T-’OO-37-XX M.]
Permit No.
RETURN OF DEATH.
BOSTON.
[ Year, / 7 & 7
Year,
/ye?
\ Years, v/f *
j Month,
Birth
Month,
Age j Months. B
1 Bay, f ''
Bay,
t
' Bays,.. ^ F
.Name in full, F //
Maiden name,
| Single.
Residence,
/Sex
JfaZe.
(. Renudrth-
Wife of
Conjugal condition \
Married.
JVi (Stipe d.
Bivaheed.
Place of death j dumber }
Place of birth,
Occupation,
Name of Father, p* Maiden Name of Mother,.
Birthplace of Father, f? * ** Birthplace of Mother,
Place of interment, : A* /\ ■< AH
f White.
I EJacJc ( Negro or mixed).
Color \ Iwdf.an.
I Cj/v^ese.
I Japm^ese.
Widow of.
Undertaker .
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
190/j
I Name and age of deceased, Age, . 3. 1
Date and place of death,*
^ f Chief cause, ...
years.
Disease
| Contributing cause,
( Chief cause,.... PPSUPirFN/...
Duration i /
( Contributing cause,
I certify that the above is true, to the best of my knowledge and ' belief.
residence ) Li/ Jf/lcur? ^ p
ician, i
Marne and
of physician
*If in an institution, state how long an inmate and previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows : — Saturdays, 9 A M. till I P.M.. except during the months of June,
July, August and September, when the office will be closed on Saturdays at 12 M.; Sundays, 10 A.M. till 12 M Holidays, from 10 A.M till 12 M ; other
days, from 9 A.M. till 5 P.M.
Thi ou /S~
Form C.
®ommonfomIl^ af IJtassaflpsetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
. (FILL OUT WITH INK. /AX
i, CbUt&AJ ULC
Name
Date of Death,
Maiden Name, jIfm^^?wed
Husband’s Name,_ Z— 1
(FILL OUT WITH INK. /K\,\- NAMES TO BE IN FULL.) ~ ,
Sex, }2dl Color,
r(
/ ; Age,. CS*!?. Years, Months, vS Days.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death, died at
Disease or Cause j ^>r^niar.v *
of Death,! j Secondary>
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence ’
of
Certifying Physician.
Date of Certificate,
(Vi ztoJ^L
M. D.
190 l .
* Give also street and number, if any. f Give sex of infant not named. If still-born, so state.
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the cleric of the city or town.
Agent of Board of Health.
7
Th'jbt/ "7
RETURN OF THE DEATH
03
73
Q
nS
o>
o
M
co
>>
ci
nS
03
03
03
£
•a a
t-
Ou
ci
03
CO
CO
<4-1
a
0
0
C3
-4-2
X
O
03
a
03
-*2
ci
1 — 1
a
03
0
CO
ns
Ci
«-l
c5
OC
03
o
03
H
03
O
12
£
03
a:
o
03
H
£
<
K
O
ci
o
03
H
03
<
a
H
X
«*-• ci
O O
0J •“
bD cj
b x:
Cj
*a
CJ O
o
X3
£
cj
'C
<0 .a
o
x:
o 'O
o
&1
03 ~
w
o 2
H
Q
W
05
>>
a
ci
o3
OP
nS
J -o
o QJ
•o
'2
CD
•c
a
eJ
.2 3
® 2 •»
b xj -<
CJ (0 CJ W
t» cj .c O
el X -
.- O
a
0
bD
73
<4-i
O
03
7*
cj
s
O
ns
73
a
'O
*-42
'S
03
CO
ci
1-.
a8
03
2
t-4
03
-42
08
03
ns
*C
au
03
a
03
-4-2
>>
"C
03
03
co
>>
t->
0
<4-1
03
L-
03
ns
03
CO
la
-4.2
«4-l
Ci
03
03
T2
-4-T
03
03
0
rG
03
03
•*2
u»
*2
rr*
— >>
u
CJ
'C
C
03
CJ
a
o
tn
)H
CJ
&.
s-
o
*3
O
fcD
CJ
a
CJ
X3
u
O
>
X3
■So i
CD
a
or
<y
03
CU
S-.
O
a
o
o>
o
03
2
la
03
o
ns
a
ci
ci co
03
03
o
-42
a
03
a
03
-42
03
ci
Od
a: g
03
03
-42
<£>
03
03
03
a
o
o
03
03
>>
-*-j
03
•*J
nS
a
ci
u, &
nS
o
t-
Ci
a
03
03
03
cr
03
J-i
W 73
<y 03
03
03
*5)
a
o
a
2
o
O
CO
la
03
03
03
2
ci
CO
nJ
03
O
00
03
03
£ +»
s-
a
o
CJ
o
nS
03
03
03
03
ci
03
co
03
03
03
-*2
03
03
bD O
a <+*
'5 bD
"5 .2
. •+— '
a 03
O co
CO
S-< (D
03 -42
* ci
03
03
03
-4-2
Ci
03
•4-2
ci
03
nS
H
03
<
03
>
CO
a
cj
03
CO
3)
•4-3
03
03
CO
03 r»
■42 ”
£ ns
03
CO
a o
- la
2 &
ns
. a
03 ci
03
03
'V
a
tX)
i-<
03
O
03
O
a o
a
03
>^> 03
t: ^
S
G O
a
.2
+2
03
03
CO
◄
a
o
^ o
a 03 a
v- co -•
03
cu
oj
CO
cj
03
•4-2
’5
bD
w 03
bD 5
a
*—• >4-1
^ °
c3 00
2 g
2 73
o
CO
c3
03
c3
Td ^
03
a
•42
CD
‘bD
03
ns
03
CO
c3
03
03
03
rs
c3
03
03
-4-2
03
03
03
H
03
<
a
H
X
w
bD
a
03
03
H
03
03
13 o*
g >2 2
‘5 ji -*
'co .£ cj
>> a “
Cj
a 03
>
c3
03
0 £-*
-42
u.
O
CO
03
a
a
0
c o
1 S
03
T3
a
03
o
Od
J-.
03
73
03
02
o
ns
.2
03 03
a 03
CO -42
a
0 ^
03
£ 0
03
03
O
•42
. ci
CO 03
73
2 ^
03
5
co
>>
0 ^
1 °
ns
0
03
3 »
cs a
ci
a
0 03
ci
*g
2
2
a
03
& 'S
O
^ ci
£
■^2
03
bD
05
c5
O
03
03
03
- O
V. &
o5
H
03 ^
o
a
03
03
o
o
V
00
or
03
-
*-
O
X
X
t-H
X
O
0
a
0
H
Q
H
O
0
cu
H
03
3
ns
w
W
a
W
a
05
05
c-
05
O
03
<N
’-42
S-4
03
03
s 4
zfi
"a
e I
®
05
ci
O
X5
0
co
X!
H
O
a
05
*0
CJ
X3
<0
CJ
c.
®
X3
a
v
X!
55 d
.2 1
6D
CJ
Form C.
(Jommonhxealtfo nf lltassadjusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name, . J&Jfk/faGLrt. Sex, fA Color, jr
Date of Death, 190 / ; Age, . Years, .Months, :A.,^A)ays.
Maiden Name, j If m^fvd^dd°wed ( L : / ...: r
Husband’s Name, 2^ CTO.., XU
Single, Married,- Widowed- »e- -Div-oToed, Occupation,
"Residence, j | ...
Jirth, /3z
Place of Birth,
•Place of Death,
Name and Birthplace of Father,.... Oar
Maiden Name and Birthplace of Mother,
. Q . O
Place of Interment, (Give name of Cemetery),
1 *■
Dated at. ..
on .../:..
ArciviP^ *s
rA^ -2.AL .190 /
Signature and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Asre of Deceased,!
(JdJtAge, / 3 Y. fK. .. M 1).
Place and Date of Death, died at (fffL A qAvs4- X . % — cAA&£U OO 190/ .
Duration, cALq&u^l
Duration,
tv n ( Primary,
Disease or Cause J ^
of Death,! Secondary,
' C-t 4 '^
1 certify that the above is true to the best of my knowledge and belief.
A m. d.
Date of Certificate, ..£A£rLdk\aidL I»L ’ 190 ( .
* Give also street and number, if any. f Give sex of infant not named. If still-born, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cauise.
Signature and Residence *
of
Certifying Physician. ,
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
04 ,//
>o. U.
RETURN OF THE DEATH
Form G.
No.
ftommoniueallfj of JltassaxJmsetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name
Date of
Maiden Name, | I£ m^^?wed
Husband’s Name, C. ZZX . . __
Single, Married, -Widowed- w Idivorccd, .■.Occupation,
•Residence S If out of town, )
xvesiuence, ; also state funy. ( V-.
Color,
Months, j$.. ....Days,
Place of Birth, Tt&tAfP (f$fdrU£>U
‘Place of Death, —
Name and Birthplace of Father,- .....
Maiden Name and Birthplace of Mother,
Place of Interment, (Give name of Cemetery),
ih Signature and (
/J place of business •< t 's-jt — — .
of Undertaker. I
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! x . ^^//Age, ^ ^ Y. ^ -M SD.
Place and Date of Death, died
Disease or Cause
of Death,!
Primary,
Secondary,
JL.t 190/.
Duration, /
Duration, - -
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence 1
of
Certifying Physician. .
M. D.
Date of Certificate,
/Yjasls&k- k.X 190/
* Give also street and number, if any. f Give sex of infant not named. If still-born, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
^ 3d
<P
rt ^
t-
05
00
H
co
rt
o
X
X
o
a
3
x
*
rt
X
.2
3
#o
3
£
a
a
£
c
H
O
rt
<u
T3
rt
O
H
O
C
3
f-
«
K
«
ao
3
O
33
(U
bD <u
O
35
£
o o
o
X
3 r- **
S O
bfi
>> 5 5
a?
>
K
a
<p
•X
H
b
K
05
ad
o
X
5 3
O "
.2 3
3
as m « >
>■3-3 0
rt 33 w <♦-
32
O
O
bD
3 3
O
'O
3
<U
'C
3
33
Cu a>
>>
32
IS
«
33
>>
33
— >>
•- *C
u C3
3 33
O
T3
3
33
3
cr
s>
tc
<u
ft.
eS 'a
rt
o
rt
<P
ad
a
a
a a
I S
a ci
2= M
o
ad
-fj
rt
P"
t-T
-*-3
rt
0)
<4-5
O
>>
<4-5
o
^a
.2
ad
•a
a
rt
E
X
CO
to
-*->
o
rt
«*—
ra
rt
^3
'rt
a
o
co
CO
CO
o
ri
a
o
X
<z>
co
a <D
a -a
rt ■**
<u
aa
QJ =
^ Fi
£ a &
<p
X
u.
‘3
C*
o>
J-.
rt
«u <p
2 £
a
o o
G 2
<p S
> o
‘So O
x «
o
t-
<P
«— J
<P
a
05
ad
o
00
rt
o
c;
be
fc-
a
a
2
*-3
t-
rt
o
o
o
o
O
CO
o
a
a
a
#a
-43)
ad
2
a
Bl
o
a:
o
X
.a a
a
a
be
a
rt
a>
a
a
X
co
a
a
ad 5
o
ad
•4-3
<D
CO
O
aa
2 £ 5
3
tD
O
£ -r
3
rr*
rt
o
<a
o a
2 o
o
E
o
be a
s- o
rt
ad
H
a
H
X
K
ad
o
3
o .ta
5 *
o
to
be
a
rt
bO cj
bO
a
a o
rt
X
y> .a
o
ad
H
3 ^
S <J
35
CO
’a
3
rt .2
31 .t2
CO j-
O
>> £
ns ~
o
a^
a
a>
bfi
rt
o
■*->
rt
a
o
a
a
a
Cl.
co
>> q
O ^
£ ^
2 rt g 2
o
ad
H
a
a
05
cd
cr* ^
<p
u<
O
fc
o
S5
o
2
>>
H
o
H
o
2 H
d. o
rt
a
a
a
a a
a
05
05
^ 05
o
<y
a: rt
3* O
a*
rt
o
X x
m
rt
o;
*C
rt
O
co u
rt
'a. ^
H
Q
a
O}
a
ad
(p
au
Q>
X
o
a
<p
32
.2 fe
Form C.
ffiammonhiealt^ nf ||tass&d[jnset;te.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(^ru. °UT WITH l^K‘ ALL NAMES TO BE IN F'JLL-)
<QM AV/iMM & xjJ/IA
ff
Name, /l/l- (/VAIA/}. S'-/)/. ZAAJIaH./X.VAVJ.J.W Sex, /.VI,/.. Color, L.
Date of Death, 'J'/'b :y>/V.J'. 3 / 190/ ; Age, V Years, ^ Months, \yTl..Days.
Maiden Name, |Ifm^^?wed|
Husband’s Name, _CZ
Single, Married, Widowed ur Divorced, Occupation,
‘Residence, { ( QAlCA/lXlk/^
Place of Birth, /^OV'/JAfY A ^
‘Place of Death, <2
Name and Birthplace of Father,. f ^cUva'sC^^’ b. LmJQ'z. Qg/avp / ux
Maiden Name and Birthplace of Mother, JxD t^/yiX0^LAu <?7/b , ^3/ c/A cblAA'/'-)
Place of Interment, (Give name of Cemetery),.
t
Dated at v:
on
(Zft
LU^L/LL^A-jLI 190 /
Signature and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! QlvuMZ Age, ^ Y. CJ M. cT D.
Place and Date of Death, ^died ^t 3/ 3/ DF) .
/ T j • i / 1 / J/1 J ^ / /f ^ ,7 V .~f yC. ^ T \ . . . t .. . .
Disease or Cause (
of Death,! Secondary,
Duration,
Duration,
I certify that the above is true to the best
V/a
knowledge and belief.
Signature and Residence '
of
Certifying Physician. ,
M. D.
Date of Certificate,
190
• Give also street and number, if any. f Give sex of infant not named. If still-born, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
return of the death
I
0
*-4 ^3
0) 43
^ rt
a .§
£> 2
0
-a
43
-33
43
OS
*2
*3
CD
and
«44
0
0
O
43
CJ
CJ
<4-4
0
c3
a
L
e
-s 5
bfi
1-4
T
a
-33
4^
.5 3
eJ
t « Ci i
>• ci O
cJ J3
o
■73
s- bT -2
«
«
.fl
-a
o
-a
&
3
33
!S JT fe»
c3
«
*0
Cm m.
■a
if
a o
o
2 a
a .ti
O -u
H
O
W
c o
►>
a
cl
cl
a:
v
cl
V
'V
3
o
as
o
.5
o .-*3
bC
if
.a
a
eS
43
>> *
w
'C
43
O
s>>
O
u
CJ
'C
43
*3
O
O
Tc
a 'S
-a
■*3
43
C"
CJ
CJ
u
rt
CJ
-a
0
c;
*-.
>3
a
t-
Q
g
5
*3
cr
CJ
E
S-4
CJ
CD
c3
CJ
43
a
CJ
<t-4
O
*» »
CJ
4-T
rj
C£!
43
S-t
2
CJ
u
V- -S
O 5
43 **”*
s «
until
CJ
E
QJ
43
rt
43
i-
5
'C
a
CJ
T
CJ
a3
o a
2 -a
tn
3
-a
rt
'O
a
rt
as .a fc
as
o to
5J <T3
a:
if
t-
C5
00
if -g
a
aa
0)
to
— i _ .a
Cj
0>
to
43
CD
cr c3
CJ £
Sm ^
CJ
a
<3
a rs
w
0
0
ci
CJ CJ
CD
s ^
-a
CD
2
43 43
-a a
43
CJ
-a
43
1 2
T a
43
CJ
cj _a
H
U
«<
.a
>
tc
a
>4
■S a
0
a:
a a
T
QJ
a:
'"C «*-4
c3
CD
O
O
a
CJ
QJ be
CJ
CJ
CD
CD
CD —
a a
-a
43
CJ
0 -a
-a 0
0
43
c3
cj a
CD .—•
«*-i
v-4
0
0
O
-a a
CJ
£ 0
CD
_, fc-
a qj
CJ
-a
43
CJ
CJ
CJ
s
0
3 cj
.3
bD
2 5
43
0
a
0
a
#r3
CJ 0
CD
1 *s
CJ
5
>
‘3d
£
a
^ Ut
0
^ a
^3
43
CJ
CJ
> ' 1
K .2
a
CJ
ra
CJ
-a
H
<3J
a:
CO
4
rt o
J3
£
«
w
E
.s p*
rs
a
c3
n ^2 43 o
„S3 <U
Ef »
o
J3
e
fcD
a 0
O
to
be a
*3 o
cl a
rs
CJ
a as
5 *
S3
pQ
CD
rt
-3
O
^3
l£
O 32
^2
t-
cj
4>
c5
r 74
43
ri
-a
CJ
C3
CJ
H4
1 — 1 —
CD
QJ
43
xn
‘3d
a
CD
a
QJ
CJ
<4-1
ing
O
CJ
O
43
<4-(
O
T
-a
CD
*-^
*n
0
CJ
CJ
CJ
O
>
CJ
rt
M
>>
“3
0
<4-1
rD
ra
QJ
■^3
cause
a
0
CD
a
CJ
rt
3
T
£
0
a
a
c3
CJ
bD
cS
CD
^ fl
CJ
p33
cj
£
a
a
o
43
J3 *-•
O
£
-a ci
£2* O
a>
rt
CJ
^2 -33
rC
CJ
05
co
C* r-l
<u
or
0
O
^ Z
a 2
>>
55
0
H
O
H
CJ
2 S
C- 0
rO
H
CJ
a
a
3 W
a
*—
C/5
05
co
0
CJ
co
c3
cj
r33
a
h CJ rj HH
CJ
*3
CD S-<
£ §
3< ^
H
O
C/5
c3 0
QJ ^
T3 Tj
c3
O
0?
-a
CJ CJ
-33 J
:|
£- °
W »-* r-j
<y cj 5
$ <u 5
rfl P
2
*3)
Form C.
ffiommonfooltfr d J|tassHr{wsetis.
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
♦
Name,
Date of Death,
Maiden Name, j If m^fcld?wed
Husband’s Name,. ^ C
Married, ~\Viduui'd ur "Divorced,
f
Sex, /.ZU. Color,
190/; Age, Years, Months, (C^ADays.
* Residence, j l{ls°0u^e & ( CJAAZLA^HJ.
Place of Birth, LAAaaJIAA
Occupation,
* Place of Death,
Name and Birthplace of Father,.
Maiden Name and Birthplace of Mother,
Place of Interment, (Give name of Cemetery).
r
Dated at .
on
aJ..QaaJj-~ (S' 190 /
Signature and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of~Deceased,t ..Age,.
Place and Dat« of Death, died at
Y.
\
Disease or Cause i ^>r^ruai.> *
of Death, X ) Secondary,
Duration,
Duration, / i
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
of
Certifying Physician
M. D.
(l . . /
( ^ f Af 190 /.
Date of Certificate
* Give also street and number, if aDy. | Give sex of infant not named. If still-born, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
cAp- i * / /
RETURN OF THE DEATH
Fokm G.
No.
Commonhxealtfr of l|tassa4msetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT/WIT If ink. ALL NAMES/TO BE IN FULL.)
Sex , . sdz. ...Color, )yh
'<dh.j(b -190/ ; A^e,. C? Years, 3c> Months, X. Days.
Name,
Date of Death,
Maiden Name, )u
Husband’s Name,_ HffZffCZ.
Single, Married, "Widowed or Pivoted, Occupation,
♦Residence, ) ^ ( QjL
Place of Birth,
♦Place of Death,
Name and Birthplace of Father,-
Maiden Name and Birthplace of Mother, ) j2/l/l/I/tyiJLy C=/V, ftlft .= fiufludi
Place of Interment, (Give name of Cemetery), L_
/
Dated at (/’!SL&L/L/VZ1*<L Signature ami
/ C, ^ i . place of business
Oil "vC //. 190/ of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,
Disease or Cause j Prin,ar'V’
of Death,} j Secondary,
I certify that the above is true to the best of my knowledge and belief.
. 1 S
fyrJb Age, 3 Y. (p. M. -k D.
(d " 190/.
Duration,
Duration,
Signature and Residence '
of
Certifying Physician. ,
M. D.
M.
A^X. 190( .
Date of Certificate,
* Give also street and number, if any. f Give sex of infant not named. If still-born, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
Q>
*G
O
*d
rt
O
ns
o
-d
d
3
d3
O
3
£
^ c
g *
Ci
00
El.
c
co
H
O
H
d
<
E
O
o
s-
C-
d
C3
O
ns
c3
-G
O
£
a
ct
o
ns
CO •-• <4-4
The text goes on. The rest is in the file.