The volume, 1904–1906
Town Clerk, Winthrop · from the Internet Archive · 602 pages · 31.5 MB
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https://archive.org/details/townofwinthropre1904wint
form C.
Cammontomltjr nf lJtassa:t|msetfs.
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death,
Full Name of
FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
*3 " 190
sed, drrcud (TdtfxZnyMs /To udtey^
If a manied or divorced
woman or a widow give also
1 Maiden Name,
I
Name of Husband,
Sex, Color, Cd Single, Marriod, W4dowod or Dlvorced-y-
Age, dV Years, // Months, / ^ Days. Occupation,
'97as2jL dke^cujb
* Residence { aio^tafe S }
Place of Death, QdcA'lAA'tsfd
Place of Birth, oCx TdbsSZxl-
Name and Birthplace of Father, ClAajd d , /d ( sfc£ey> SH'JZA
Maiden Name and Birthplace of Mother, / }/L >'■ l O' t /.O^i^gA c^'^-
! Signature and (
4^-— 190 of Undertaker. j (Id)
Place of Burial (Give name of Cemetery),
TJ&./L
Date
on
'yi/t&uQ^
7
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! /\dddk ZSl Ct d~ ? ^ )f.X ^ Age,cT^ Y. M . /X-< D.
Place and Date of Death, died at ... 3 190 <jT
... ,, ( Primary, Duration,
Disease or Cause ) J /
of Death,! Immediate,
Duration,
I certify that the above is true to the best of my knowledge and belief.
- C2Ur2 Si^X Z_.
Signature ami Kesidence 1
of
Certifying Physician.
M. D.
/d?A. .. o d
Date of Certificate,
cr^ny.
190>5.
7
* Oi?c alto ntreet and number, if any.f f Ulvo sex of infant not named. If Btilbborn, »o stnte.
. If a Soldier or Sailor in the War of the Rebellion, giye both Primary and Immediate Cauae.
Countersign and transmit to the cleric of the city or town.
,d?Y s' d? xd
(Si. — -
Agent of Board of Health.
return of the death
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d^
Permit No.
OF DEATH.
f Year, ,
Year, [
j Month, .yfi&fy?.
Birth
j Month, . . . & * " -^ge i
1 Day,
1 Day, $
.Name in full,
Maiden name,
Fesidence
Years,
Days,.
,./ 6 o* :/ Vl. •
Sex ,
Male.
(. Female.
Conjugal condition
f Single.
| Married. 1
| Widowed.
I Divorced.
Widow of.
f White.
\ Black (Negro or mixed).
Color \ Indian.
I Chinese.
I Japanese.
Wife of
Place of death\ ^eet’ j
J umber, J ^ ^ s -
Place of birth,
Occupation,
Name of Father, ^bu***&c J^f^^^^Mfaiden Name of Mother,
Birthplace of Father, ' Birthplace of Mother.
Place of interment,
Ff. W , 2
Undertaker .
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
Boston, *J 190 y
Name and age of deceased,, *1 y vjh ..Age,.,. 7 ' y years.
Date a,nd place of death,* /U
I Chief cause,
Disease
Duration
I Contributing cat
{ Chief cause,
i Contributing cause,
tFLA *
// )
I certify that the above is true, to the best of mu knowledge and belief.
...MD.
Name and residence |
of physician, )
•If In an Institution, state how lonn on Inmate nud previous residence. J L/ /]/] ii A/C
The office of the Board of Health will be open for the granting of per mitt for burial, as follows : — Saturdays, 9 A hTtlll I P.M , except during th£ months of June,
1 AT>Wl/WV(J\w'
I P.M,, except during th^ mon
July, August and September, when the office will bo closed on Saturdays at 12 M. ; Sundays, 10 A M. till 12 M ; Holidays, from 10 A M. till 12 M ; othor
CITY OF BOSTON. COMMONWEALTH OF MASSACHUSETTS.
RETURN OF A DEATH-1904.
full name Annie.. . 1£. . ,M.c.G.r.e. al Registered n© 354
Plac,e °f ,?eath £ Er.ee. .. Home. ...f or. ...Consumptives. .. Quince. ..S.t Boston Mass
and Residence j ^ ^
Age .1.0. years months 2.5 days.
Date of Death <X.9Ji..l.l.
1904.
STATISTICAL DETAILS.
PHYSICIAN'S CERTIFICATE.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
I HEREBY CERTIFY that I attended deceased during last illness,
female .... .whi.t.e single •
Maiden Name
from 1904 to 1904,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Husband's Name.
iS): J Eul-. ...T.uber.c.ulos.is.
Birthplace East- Bo. ston -Mass 5.. ..months
Name of T
Father J .310.6.!
Birthplace T n
of Father Ireland.
Contributory :
(Duration)
Maiden Name
of Mother
Birthplace
of Mother.
Winnif red Welch.
Ireland
(Signed) ”&hn B "reanor m.o.
Occupation D.Qfflaati.e. da:: If. r..4
Informant..
SPECIAL INFORMATION from Hospitals, Institutions, Transionts, or Recent
Residents.
r!aCremovBa7.'.al .¥.0 ly... Cr O S3 .Mal.d3.il.
Usual Residence W.in.t.hro.p....Mas.s..
Undertaker S.uraner....E.lQ3r.d.
Filed lari... .14.
1904.
A true copy.
Attest :
Registrar.
CITy
Form C.
Commoniufriltlj of Jltassailjusetts.
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.)
Date of Death, U iX n 1 < / 5 ff 190
Full Xame of Deceased, J J lutAlAP’J' C/ / / i.lA„
If a married or divorced
woman or a widow give also
1 Maiden Xame, J&... uwA ii/sn. ty3--.
/ Xame of Husband, fS '/L. Jl M.1 U 0 1 UP >
Sex, Color, // /'HA*. Single, Married-, WidiJimt-ui Di'i'uroed,
Age, // Years, Months, /tJ Days. Occupation, "
* Residence { Kafe S } S/" ..A' ' ^
Place of Death,
Place of Birth,
//
rs
'f
ff
Xame and Birthplace of Father
.
, crfviA^.
Maiden Xame and Birthplace of Mother, C^/lA/^-y
Place of Burial (Give name of Cemetery), //''l. 1. tr^
Dateoh'cit.. Q.ju.i.1 i... LA_ k- JP Signature and l
\ I ./r — . / place of business l
0^, :j.qLU.iAJ.^ J\D 190 ' f of Undertaker. ^
PHYSICIAN’S CERTIFICATE.
Xame and Age of Deceased C^£u eg* C?U/1 PH Age, 4^^ Y. / ^LJ).
Place and Date of Death, died at USIArr' Mf '■ 190^
\(
W Jltcu*
V
/ ^ lAA^/PnU^ &P&/
A
Disease or Cause
of Death,!
Primary,
Immediate,
,CXAAs^.Ary:.\AU\.
Duration, ...
ac~f
.. Duration,
1 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 L
1901/
• Give also street and number, if any. f Give se^ 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
Form C.
Cantmoniwdlfe of lllassacfritsetls.
y*
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.)
s, * . J . / J 1 '/
Date of Death,..
Full NameW l5eceased,
If a married or divorced
woman or a widow give also
'i Maiden Name,
J Name of Husband,
Sex, Color, C22 Single, M-awiarl, WiM owed ™
Age, b Years, ^ Months, Days. Occupation,
* Residence { Ktafe fun£ }
Place of Death,
Place of Birth,
Name and Birthplace of Father,
(J' f (^n CJlA^z
s r
Maiden Name and Birthplace of Mother,
Place of Burial (Give name of Cemetery),
Signature and
place of business
y place of busines
.190 of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! i Age, ^ Y. M. C D.
Place and Date of Death, died at .s? £ If f ^ 190 /£
Disease or Cause i
QM)eath,t j Immediate,
i J
Duration,
- Duration,
%
certify that the above is true to the best of my knowledge and belief.
(2 u '2rh
..-.(22... ~^~2\ pj&i/Z-'
Signature and Residence ‘
of
Certifying Physician. ,
Date of Certificate,
(M'V...
190
H
• Give alto 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 Immediate Cause.
/
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
return of the death
[ll-’02-37-LM.J
Permit No.
RETURN OF DEATH.
[, MASS.
Name in full, fZPNlNf yff
Sex, x
(If a married or divorced woman give mahU*^ name, also name of husband.)
Color,.. Condition,
(White, Black, Mixed, Chinese,
Indian, etc.)
Age, y' X Years, . fJ- Months, X 6 Days. Occupation,
_ f / xi ~ /
(Single, Married, Widowed or
Divorced.)
zee, ..tf~ ./
Ilekidence
Place of Death, .4. X...
Place of Birth,
Name and Birthplace )
of Father, )
Maiden Name and )
Birthplace of Mother, )
Place of Interment,
Ward,
/?
(State yeai*jAftonth and day.) ..
Date of Birth, X A I fL ' ““V A^oZj
Undertaker.
PHYSICIAN’S CERTIFICATE OF THE CAUS5 OF DEATH.
Boston, r-o 0 ' 190 M,
n . . A - u X
l'sf(,ie } Age, 7/ years.
( Chief cause , C JLr\ 0 LlX>
“J -a J / 10
Name and
of Deceased
Date and 1
Place of Death * '
Chief cause ,
Disease i v .
( Contributing cause, 'yrv/j -
Duration
j Chief cause,
( Contributing cause,
/ certify that the a, hove is true to the_best of my .knowledge and belief .
-
Name and Residence 1
of Physician, )
* If i»n Institution, state how long an in mate and previous residence.
7 1
Form C.
(Kammontaltfr nf lltosarkxrsetts.
umpire' ^
.Vo.
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.)
Date of Death, 1^/11/ X" 190 *
Full Name of Deceased, W4 tJfxZ- ^ r
If a married or divorced
woman or a widow give also
1 Maiden Name,
J Name of Husband,
Sex, 7iv Color, 04- Singlo, Married, Widowed or Divorced,
Age, Years, Months/ ^ ' Da^s. Occupation, -C^P ^44/^24/^Co ,
* Residence / SAuJU
Place of Death, jb / gD/fi,
Place of Birth, AO/Ul^UJ^ jAAjfcz
Name and Birthplace of Father, AoAlOZf. Jt&gJ Jh,
ItfdZAt t4-^-
Maiden Name and Birthplace of Mother, f&) rAcO
Place of Burial (Give name of Cemetery), 4^3 Ajp>
Datech^t ..
on QotlAldJJOUU^ -fiS.. _190 A
Signature and
place of business
of Undertaker.
yi
& 2Woaa..
....
yd) fab/
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, f Age,. ^ /. Y. — - ~M .
Place and Date of Death, ! died at.
Disease or Cause j ^*™Uiar^’
of Death 4 1 Immediate,
£Azl.
t Hr &-
190 Y
Duration,
- Duration, djsJhLJ^*
1 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, ZJ*Z 190^f
0^-2^'
• Give alio street and number, if any. f Give sex of infant not named. If still-born, so stale.
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Immediate Cause.
Cowitersign and trarmrut to the clerk of the city or town.
Agent of Board of Health.
No.
RETURN OF THE DEATH
Form C.
No.
®ommnnh)taIt(} of |flassacbusefts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death,
(FILL OUT WITH INK. ALL NAMES TO BJE IN FULL.)
^5 &
//
190
Full Name of Deceased, " Cf f/ f / -cu, ckfO
If a married or divorced
woman or a widow give also
1 Maiden Name,
» /
) Name of Husband,
Sex, Color, kk Single, Manned, Widowed or Divorced,
Age, ^5^ Years, (k Months,
* Residence { stafe mi?:
Place of Death,, y uo t
Place of Birth, J
Name and Birthplace of Father,
Maiden Name and Birthplace of Mother,
Place of Burial (Give name of Cemetery), ..
Days. Occupation, x —
oS fy>. / / /~ — 1
S^yj
ktkkyk , y M' ^ kkyfj * •' tyk lynAJ.
Dated
on
z CK
id ats- iZl-llL
ft. 190^ ’’iTcndenake?-99 ( yj^ kyps 10 'U„y -
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! (^JkldAAL CL.. yjk^Q.k^oAij Age , ps-.. Y.-.&2 M . k D.
Place and Date of Death, died at Qh&il ^lZjs/o mju^ua. zy JL_. - 190
S'* /
Disease or Cause j ^>r*lll,a.' >
of Death,! j Immediate,
Duration,
Duration,
1 certify that the above is true to the best of my knowledge and belief.
^..T— -c M D
V ) //yjs/cc
Signature and Residence '
of
Certifying Physician.
Date of Certificate,
190 .
• Give aUo street and number, if any. f Give sex of infant not named. If stubborn, so state.
| If a Soldier or Sailor In the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the cleric of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
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Form C.
(Cammmxiwdtfc of IJIassaxfjnsetts.
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
fT' (FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Date of Death, Q r/ ' ' 190
Full Name of Deceased, / (/MA-^-fX- SlAj
I If a married or divorced
| woman or a widow give also
Sex,
'j Maiden Name, ^ 7 rZ
/Name of Husband,
Color, M ■Singila, Married, mdowccl or Divorced,
Age, Years, r Months, / ^ Days. Occupation,
* Rfidence { Ktafe | • ^
of Death, *y QJ fnA-/ \y
Pfece
Place of Birth, (D CulOI) Tl&HL .h^nJ/2,.
Name and Birthplace of Father, %J. Vcf ~ dz>. (Ay?. AlJlJzJjLriLdAL^.
Maiden Name and Birthplace of Mother, A2J ..LxjldA*@.JL/- ' 1 CL A'AOC " (I'Q.J '
Place of Burial (Give name of Cemetery),' i(^ CLLt^JhCLyLA^J ^ CAd/ULL^QAlLiA AL) t^ALAL. (ALA 9- l ■'
CMr,2>MAZ1h Signature and ( ...f^X^....lL^A\AfA AtosPj'fjnfcl
place of business ■{ qs , / (J .
fo ^Miaaaaoai^ a) UmJ
190 U'
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! ^OAJJLALQL 7 '2A/.. t. Age,^/ C Y. M. A A...X)
!(
I
Place and Date of Death,
Disease or Cause ( FAm^
of Death, t i Immediate,
died at..y^.L \ 90 ^
XJtS Duration,
.xPgfaj Duration, 3> \aj-LlAJ S,
I certify that the above is true to the best of my knowledge and belief.
i M<JT
Signature and Residence ’
of
Certifying Physician. (
M. D.
Date of Certificate
icate, ™lhxJv~l—
190 y.
• Give alao street and number, if any. f Give sex of Infant not named. If stillborn, bo state,
t If a Soldier or Sailor In the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
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CITY OF BOSTON. COMMONWEALTH OF MASSACHUSETTS.
FULL NAME..
Place of Death )
and Residence J
Date of Death
RETURN OF A, DEATH— 1904.
Altoer-t-.E-Surapt-er- Registered n0 1&33....
.S.o.u.tii..D.e.p.t....C.i.t5:...Jio.sp.i.tal...JBo.s.t.Qn..Mas.a
..E.e.'b....£8. I 904. Age.. ...1.0. ...years. -.6 months.. 15..... • day*.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
mala single
Maiden Name -
Husband’s Name
Birthplace .Er.Q.cl.t.Q.n...Mas.s.
Name of _ ,
Father - Er. ank
ofrtFather. ,¥.ss.t.b.ar.o...Mass.
.0.ms.a..J....Hg.ffi.i3M.
Birthplace _ TT ,,
of Mother S.a...Jxanson...-m5.s
Occupation fl.Q.0.6.
Informant
Place of Burial
or removal
Undertaker J-S - ■ • Ha -t Q man- -&-S © HS-
PHYSICIAN’S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from I 904 to 1904
that to the best of my knowledge and belief death occurred on th
date stated above, and that the CAUSE OF DEATH was as follows
(Pd!S: J .Maaal&a. 2..9....day.s..
St/on) ' tory : j C.ong.e.ni.ta.I...Hy.dr.Qce.phaIU3.
r.e.ars.
(signed) lo.hn....H..M.c..C.Qll.uxa m.d
.F.S.b. .. .28. .. 1 904
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recen
Residents.
Usual Residence .^4.7.. ..Shirlsy... .St... Winliirp.p.
Filed
A true copy.
Attest :
Mar-2
1904.
Registrar.
ClTy
Form c.
Xo.
Cammonbxmllfr d
RETURN OF A DEATH.
m k
To the Clerk of the City or Town in which the death occurred.
^ /"* (FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Date of Death, 2 ^ ' JlM* <^.^190
Full Name of Deceased, L'C Y 7 / i tCC ■ ' y/ ( 1 C7? rf J
( 'i Maiden Name, C^C^C '? / r
J If a married or divorced ' I
I woman or a widow give also C __ . /T. , , . - . ,
( J Name of Husband, (iff. 1 7? X.^.7a...c£ / > /
Sex, Color, J . A - Singley Married, Widowed or- Di-vereedy
Age, Years, 7 C> Months, Days. Occupation, - ^
* Residence |^S! ^ 2 j
Place of Death, cQ'/? 2')J/L4.4£tA,L 22.J Twr
Place of Birth,
Name and Birthplace of Father,
Maiden Name and Birthplace of Motheryl... ./<£?
Place of Burial (Give name of Cemetery), .... // IT.T^^'zTX 7> ( c? /
Signature and ( tl (<13??..
c^irn . f - ^..;^\ Yr.^^sv v.
. >f c M
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/^c
Dated at
on
c?'*'* 190^ of Undertaker. (7 <7 >
■ - - ■ — - ■ ■ -■- ... — . - ■■■■ C*-$g
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! ££^r*v<*. '^ZJ c±J%tsns~ Age, ^9Y. / ^ M. /f
y 0 , * * y / y/ • . — J cficd~ A y/
Place and Date of Death, died at Z Yf4. *v ty
... ( Primary, /%]/ Duration, 2<
Disease or Cause > J 7 7^
ot Death,! /Immediate, ( '2 .< Duration, 70
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence ‘
of
Certifying Physician. ,
4^
Date of Certificate
, 7ry^, 4ud
19(V^f
_M. D.
2zi.f^cv-
• Give also street and number, if any. f Give sex of infant not named. If Atill-born, ao state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
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Form C.
®amm0niuer<ltfj nf Jltesaxfrusetls.
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.)
190 ^
A- (T VC (fj
If a married or divorced
woman or a widow give also
Date of Death, / L/12 (2 A y /
Full Name of Deceased,
} maiden Name,
„
Name of Husband, L
Sex, Color, J /' Single, Married, Widowed or Divorced,
Age, ^ 0 Years, / C Months,^ Days. Occupation, ^ f^/122
* Residence {Kuteffi} ^ C? J , /S LuJj ' ^
Place of Death, / / C?) f /A.
Place of Birth, /I I.A2. 4A * y JpZ n % $/
Name and Birthplace of Father, Q /*>)//(({+.■ ^ J< ^2. JiU /. ./ /It
Maiden Name and Birthplace of Mother,
Place of Burial (Give name of Cemetery),..
Dated at
/) X | . place of businee
Oil / (f XXCAA/. oL/. - 190 A of Undertaker.
(a IujlT
PHYSICIAN’S CERTIFICATE.
> jS LfrVCX- Age, (dC Y.y^ M.^,1).
Name and Age of Deceased, - ... - ——
Place and Date of Death, died at )yV2...2k.
Disease or Cause j Primar^’
ot Death,f 1 Immediate,
W-?. . 190 r/
^.^...^^.^..190
ration,
' ’ y'‘
^^/cbJ>'V-^Acc
uration, /jf
I certify that the above is true to the best of my knowledge and belief.
C-y M. D.
Signature and Residence
of
Certifying Physician.
Date of Certificate,
• Give also street anti number, if any. f Give sex of infant not named. If still-born, bo state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
return of the death
+lw» r.;t v nr fnwn for l'0,yistnitioU
Form C.
y o.
ffiomntonixrmllfe flf lllassaifrttsetts.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death, ■ Jx. ^ '
IFILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
4/
Full Name of Deceased,
) Maiden Name, C:.
UzLAau.
If a married or divorced
woman or a widow give also [ __ „ „ . . * J) _
J Name of Husband, tfcdsu J VZAaS.
Sex, / Color, 'Single; Marriod, Widowed or Divorced ,—
Age, 7' Years, Month?; Days. Occupation,
* Residence {L'r.uaS”:) QzA
Place of Death, ^4 ‘/'It {./ r v i /& IdJ1 pS
Place of Birth,
Name and Birthplace of Father,
Maiden Name and Birthplace of Mother^. l/ /
Place of Burial (Give name of Cemetery), 6^7%^?/ /rp,
'l/Ll.4±.r/>
Dated at
yVioucAj
on
£
Signature and
. t place of business
190 yA of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,
Disease or Cause i
Age,
Y.
M.
D.
died at. *J ^ 1 90^ .
Duration ,**• HX^L^L
of Death, t / Immediate,
Duration,
1 certify that the above is true to the best of my knowledge and belief.
a^L.e
Signature and Residence
of
Certifying Physician.
trsq&Me+'c .
iticate, lO, 1904.
Date of Certificate
• Give also street and number, if any. f Give sex of infant not named. If stillborn, so stnte.
J If a Soldier or Sailor in the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or toivn.
•1 gent of Board of Health.
RETURN OF THE DEATH
Form c.
ffiammonfaealtfe nf Jllassarfrusetts,
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.)
/y 190
cf t l/ tr-u&o
— iriLu ww i wiin imrv. y
Date of Death, /W/usA^ y f
Full Name of Deceased, /doiaw
{1 Maiden Name,
If a married or divorced 1
woman or a widow give also f
) Name of Husband,
Sex, tkJ Color, OAy Siftg'lo,- Married, Widowed or Divorood,
Age, / Years, Months, / Day^. Occupation, ¥
* Residence
Place of Death, 4 /f ,
Place of Birth, 0 ^ ^ ~
Place of Burial (Give name of Cemetery), QA(ZJZa&Z?yis ?/) AiZ4i
/tfOk/.
Name and Birthplace of Father, /j^
Maiden Name and Birthplace of Mother,
Dated at
on
fM,
fth^M£A^.JS¥ .1905^
Signatme and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! /O. Age, .*//. Y.—^—M
died at..__ 2%*h^!X-
___
Duration, ,2j
Duration,
Place and Date of Death,
Disease or Cause j ^>”niarl >
of Death,! ) Immediate,
/ D.
190^
1 certify that the above is true to the best of my knowledge and belief.
iLC 2«^;_
Signature and Residence "
Of
Certifying Physician, i
_M. D.
Date of Certificate,
14... 190#
• 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, givo both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Jfealth.
RETURN OF THE DEATH
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RETURN OF A DEATH.
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(FILL OfJT WITH INK. ALL NAMES TO BE IN FULL.)
Date of Death,.
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.M. D.
Date of Certificate,
190^<
• Gire also street and number, if any. f Give sex of Infant not named. If stillborn, ao state.
| If a Soldier or Sailor In the War of the Rebellion, give both Primary and Immediate Cause.
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Agent of Board of Health.
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RETURN OF A DEATH.
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(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Date of Death, j / /y(2 4- @4^ ZZZ2 7/ .190
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Date of Certificate,
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• Give also street and number, if any. J Give sex of infant not named. If still-born, so state,
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Form c.
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Commottfomltli oi ^^BSKt^nstits.
RETURN „#F A DEATH.
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Date of Certificate,
M. D.
%AaAj.
J2=M 190 3
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t 1/ a Soldier or Sailor in the War of the Rebellion, give both Primary and Immediate Cause.
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Agent of Board of HeaU.lL
RETURN OF THE DEATH
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Cammonbxeftltfr ai Sassarfeusetts.
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.)
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Date of Death,
Name of Deceased, aO/1’ /J2oatuj2J^
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Dated at
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Signature and
place of business
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Undertaker. ^ i2AaA.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, f Age, OAt. m.c^d.
Place and Date of Death, k — ^ died at.. Q4^.(Xalm^.. A 190 A
t, . ( Primary, Qrfk Duration, t &A.
Disease or Cause J \ p A
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1 certify that the above is true to the best of my knowledge and belief.
V A- \|V
Signature and Residence '
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Certifying Physician. .
Ucs
M. D.
cT —
Date of Certificate,
190
• Give alto 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
■Ujent of Board of Health.
RETURN OF THE DEATH
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Form C.
J Vo.
©ommonlwJtl^ d l|Iassat|ps£tts.
_ &\ jJ*
\Ak fee V)
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.)
Date of Death,. /J/QCU <&. t
Full Name of Deceased,
( Maiden Namd,
J If a married or divorced 1
I woman or a widow give also [ . 1
f ) Name of Husband,.
Sex, Color, Gf ■Singlo, Married, W-idowod ui Di > oi'cud,
Age, ^ ^ Years, Months, / ^ Days. Occupation,
* 'RpciHpnpp f If out of town, 1 ' ™
xiesiuonce j also state fully, j
Place of Death, CLfMAHJL'
Place of Birth, /Quy^t
Name and Birthplace of Father,.
Maiden Name and Eirthplace of Mother, iCA”',!.' I ' i / • ' A''
Place of Burial (Give name of Cemetery), ... ' OlA^\
Signature and
^ / place of business
190 f of Undertaker.
^ UyinAAAj?Ju rP^pAfrJj
PTH PJlMA m / UmJ
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! Age,^/^ Y. ^ASl. /
Place and Date of Death,
Disease or Cause ^ ^niar} »
died^at <&.(?.. 190 ^
Duration,
of Death,! j Immediate, I - Duration,
I
1 certify that the above is true to the best of my knowledge and belief.
>?-, <2 - 2? l/~T
Signature and Residence » "
of
Certifying Physician. .
4? C/^yc^-gat^-
...Mh d.
Date of Certificate,
190
• Give alio street and number, if any. f Give sex of infant not named. If still-born, so stnte.
| If a Solriler or Sailor In the War of the Rebellion, give both Primary and Immediate Cause.
. „ r -
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Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
^o.
return of the death
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Form C.
Cammontedtfc al IPassaxfcimtte.
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.)
190
<n
Date of Death,
Full Name of Deceased, S/AJ^OlJn?XL
{) Maiden Name,
If a married or divorced 1 /V) '
woman or.„„o.Si.. ..so |Name q(
cXX nj (y v
Sex, Color, s" -Single, Married, Widow od or Divoroou,
Age, 3 Years, ^ Months, V* Days. Occupation,
* Residence {JLTJS&®:} " ^ ZXX. fi ^
Place of Death, / ^ /@ XuXJ
Place of Birth, ' X/ff X/A 'lAyfiZ ........ Z3 ~
Name and Birthplace of Father, L ZaZamA 3Z ytyv ulO_. & Y/UZ^.Z
Maiden Name and Birthplace of Mother, /oaXZZiyuys^
Place Of Burial (Give name of Cemetery), CZ^XZ.ZZZo-^ o r/Wcyy ^ (/
Dated at -. Signature and (
Oil ' 190 Z 1 oTundemker!8 | _ / j? OV PAAA4 r/M, xS> Uf/J
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! ckZaaZ/ /^Y. fM. ^1).
Place and Date of Death, died at ,.. pLxM^o L ytiol. **., 190 *<
„ ( Primary, 7As^/ . Duration, A?.)
Disease or Cause ) J fin v fr-
ot Death,! j imme(iiatej CZl^c^tZ' Duration, .<?. Cx^joA .
1 certify that the above is true to the best of my knowledge and belief.
Signature and Residence ‘
of
Certifying Physician. .
Date of Certificate, Zsf.
190^
M. D.
• Give also street and number, if any. f Give sex of infant not named. If stubborn, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
Form C.
/'/'■
J Vo.
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.)
Date of Death, <f& / '' 190“/.
Full Name of Deceased, .4tzrv^~
"I Maiden Name, ,
0iTt ai..o j -^ame Qf Husband, — . (■ J. -
Sex.- •«!>..£/. Color, . t /. , rl Single, Mariied, Wiilotvcil 01 Bivurced,
Age, ^^^Years, Months, r <- “"-Days. OeeupatioTT,
If a married or divorced
woman or a widow
* Residence { “s^tafe fKJ: i
Place of Death
,
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Place of Birth,
Name and Birthplace of Father,^
Maiden Name and Birthplace of Mother, J.A-c£tc.(J3.tr ,
Place of Burial (Give name of Cemetery),
f
Dated at — tL
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on
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, place of business / . p*’ ^ / C / ' j
190 // ' of Undertaker. / ,V C/ty f ,< / ; '/ JW' C4£C/
Signature and
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PHYSICIAN’S CERTIFICATE.
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Place and Date of Death, died at 1 'JSjL 190 ^
i Primary, — - Duration,
Disease or Cause 1 J
of Death, t I immediate|
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence ‘
of
Certifying Physician. ,
.Cl
M. D.
Date of Certificate,
-Su, JV
!tf3.
190
• Give aleo street 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
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Form C.
Cammonbxedtk of lllassarlwsetts.
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.)
Date of Death, -Px <=$/ * 190
Full Name of Deceased,
( 1 Maiden Nam^, V
J If a married or divorced 1 /") // // X
\ woman or a widow give also i __ „ , ( / 9 ~*iyY S (P l/x/ is- < _
( J Name of Husband, / O, /T^x >• U/Ls
^ y >"'/
Sex, Color, Singlo, Marriod, Widowed or Divorced ,-
Age, Years, , ^ — - Months, c — Days. Occupation,
* Residence { fu^: }
Place of Death, ~aXX Cfae^isce^ Qy ->
<f) J . *
Place of Birth,
(5?/2
Name and Birthplace of Father, '<--yo~?9l!®6t
Maiden Name and Birthplace of Mother,
Place of Burial (Give name of Cemetery),''
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Signature and
s2>~. 190 ' of Undertaker. Sft \ ^!L 2 t ,.SS\lAl
yJl^WVV.^
PHYSICIAN’S CERTIFICATE.
i'ame of Deceased*,
’lace and Date of Death
Msease or Cause of Death :
Chief Cause,
jfiosed Age, ..
h, No. id"?;
O <=)^J-Q,LL-L >. mo y^
Years, jOrrr Months,
(jX\\JryrJj
DURATION.
Contributing Causet
Place where disease was contracted, if other than death,
certify that the above is true to the best of my knowledge and belief. \y~ /J XT// /->*/ ///vO
Signature of Physician, ^ • M ^ M. D
Residence, No
Street,
(City or Town.)
( Or Sex of Infant (not named).
If a soldier or sailor who served in the War of the Rebellion, Chief aiyl 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 f.m. ; Sundays
md Holidays, 12 m. till 1 f.m. ; Other Days, from 8 a.m. till 4 p.m.
BE VERY CAREFUL TO FILL ALL BLANKS IN INK.
[over]
Agent of Board of Health.
RETURN OF THE DEATH
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Form C.
ffiommonbxealtfr of lllassatfewsetfs.
jfe ^ '/''
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death, ^ ^
Full Name of Deceased
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
190 ^
If a married or divorced
woman or a widow give also
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Sex, Color, 9f Single, Mari iul, "Widowed or Divorood,
Age, (pO Years, C Months, C Days. Occupation,
> * Residence ^
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Place of Birth,
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Maiden Name and Birthplace of Mother,,
Place Of Burial (Give name of Cemetery),
Dated at
on
22.. 190 4^ 1 Of Undertaker. ( AT PJ f&M J S> /
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! Age, ^^ Y.
M.
D.
Place and Date of Death,
died at
% 1 90
Disease or Cause j ^r^mar3 ’
of Death,! ) Immediate,
Duration,
Duration, ^2-
1 certify that the above is true to the best of my knowledge and belief.
Signature and Residence '
of
Certifying Physician.
M. D.
Date of Certificate,
190>^
* Give also street and number, if any. ( Give sex of infant not named. If still-born, so stnte.
J If a Soldier or Sailor In the War of the Rebellion, give both Primary and Immediate Cause.
uoaL and transit to the clerk of the city or town.
Agent of Board of Health.
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RETURN OF A DEATH.
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RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALU NAMES TO BE IN FULL.)
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Date of Death, ' ' 190
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Dated at \/t^CA^A- Ll. - Signature and
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Oil Cc^^/NAJC? ^L-— 190 y- , of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,
Disease or Cause i ^ 1imar3 »
of Death, J j Immediate
1 certify that the above is true to the best of my knowledge and belief.
• 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
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RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
, a;
(FILLjOUT WITH INK. ALL NAMES TO BE IN FULL.)
Date of Death, '^C4QMJb/] ^LS) " ..190 </
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of Undertaker. \ /jf XjfyPsUUt
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PHYSICIAN’S CERTIFICATE.
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(2vUaup. tQ/oaPU 190 44
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I certify that the above is true to the best of my knowledge and belief.
M. D.
Signature and Residence 1
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Date of Certificate,
* Give also street and number, if any. f Give sex of Infaiprnot named. If still-born, so stale,
t If a Soldier or Sailor In the War of the Rebellion, give both Primary and Immediate Cause.
/
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Countersign and transmit to the clerk of the city or town.
e. p^7....acsz~./s£ jrc«c-ju
Agent of Board of Health.
RETURN OF THE DEATH
Form C.
ffiommnntaeallfe of lllassarfrusetts.
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death, 2U>
Full Name of Deceased,
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
190 ^
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Age, £ 0 Years, 3 Months, Days. Occupation,
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Place of Burial (Give name of Cemetery), — ^ ^ (A
Dated at.. Signature and
On t£?.. 190 1 of Undertaker. [ / l/f f7
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! S-ciMs
Age, & ° Y — i$_M. f£/.D.
Place and Date of Death, died at
Primary, Duration, /* ' ^
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of Death,! j Immediate,
i certify that the above is true to the best of my kna
Signature anil Residence
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Date of Certificate,
• Give al#o street and number, if any. f Give sex of Infant feocnained. If still-born, so state,
t If a Soldier or Sailor In the War of the Rebellion, give both Primary and Immediate Cause.
^ to. D.
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Agent of Board of Health.
RETURN OF THE DEATH
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Commonfotaltfe uf IJtassarJmsetls,
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death,
Full Name of Deceased,
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
,f 190
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If a married or divorced
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PHYSICIAN’S CERTIFICATE.
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Place and Date of Death, | died at. ^ 190 (y
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Date of Certificate, faLot-y.. Y _. 190
* Give also street and number, if any. | Give sex of infant not named. If still-born, so stale,
t If a Soldier or Bsilor in the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Jfealth.
RETURN OF THE DEATH
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CITY OF BOSTON. COMMONWEALTH OF MASSACHUSETTS.
CITY
RETURN OF A DEATH-1904. BOST
full name Munr.Q.e....G...!Er.&w:3.rgy. .... Registered No. ...4284
p|ace of Desith £ B.os.t.on C.a.me.Y:...Ho.s.Qi.t.al
and Residence ) J ^
Date of Death JjL.3I7!....X2 1904. Age 52. years months days
STATISTICAL DETAILS.
PHYSICIAN'S CERTIFICATE.
SEX COLOR | SINGLE, MARRIED, WID., DIV.
.ma.l.e. .wiii.tel jnarr.ied.
1 HEREBY CERTIFY that 1 attended deceased during last illness
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows
Primary : j G.ejI......P.ar.l t QH1 1 i.S
Husband’s Name
Birthplace S.ur.ry....Main.e
L week
Name of _
Father Z.ei 13.3.
o f rtp at h e r Surry Maine
Contributory:! Appendicitis 48 hr
(Duration) j
Mehltable
ofrtMotahCeer Surry Maine
(Signed) A..G..KllMurn. M.D
May. .13. 1904
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recenl
Residents.
r!aCremovBaT' a !..l X. nt h r.Q.p .. . Cem.. V/.in thr.o.p....Mas.s
Undertaker Sumner Floyd
Usual Residence .WlXlthCOp . MSS.S
Filetf.ftX.14. 1904
A true copy. ^
‘
Registrar.
[ll-’02.37-LM.]
/> ^Permit No.
RETURN OF DEATH.
BOSTON, MASS.
Name in full,
Date of Death,
l y/ / C/n * % ('■ / 7 X Xx
r '
Sex,
M-
(If a married or divorced woiuaru give maiden name, also name of husband.)
* Condition, ®
Color,
y White, Blrtrk, Mixed f Chinese,
Indian, etc.1
(Single, Married, Widowed or
DrvoreeiL)
Age, Years, Months, : Days. Occupation,
Residence, m3 J£=. — Ward,
Place of Death, 3 3 XX v^' <A *V '
yg (State year, month and day.)
Place of Birth, / IfDyY-. 3 /< ( ^ y/ Date of Birth, No / ? <?Xy
Name and Birthplace i /&- MPC xNMP /T^ /3r<
Maiden Name and [ dfC'
Birthplace of Mother, )
Place of Interment, t
' X* xxXB
Undertaker.
CXq/?
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
^7333 Xu-? zcTt 190
Name and Age I
of Deceased , )
Date and )
Place of Death,* )
Disease
j Chief cause,
:•/?
Contributing
7
Age,
190.77.
years.
* | Chief
Duration \
cause, ...
Contributing cause,
I certify that the above is true to the best of my knowledge and ’ belief.
Name and Residence I
of Physician,
XdXcMXd AM
TAst
M.D.
* I f an Institution, state how long an Inmate ami previous resilience.
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
/>?
<.?
<
FULL NAME
Place of Death *
Date of Death
DEATH
; 1 . .1 .J. Registered No
days
ST AT IS
txeAE
DETAILS
SEX
9>r
COLOR
OV
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE -r
/ V oPA
NAME OF ^7
FATHER
BIRTHPLACE
OF FATHER*
MAIDEN NAME , ,
OF MOTHER S^?Z. dc T.
BIRTHPLACE
OF MOTHER t
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
UNDERTAKER
DATE OF BURIAL
190 .
^ / t- e
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from . 190 .^fto 190 ,
that to the best of my knowledge and belief death occurred on the
date stated above, and tftat the CAUSE OF DEATH was as follows:
Primary :
.(duration) DAYS
Contributory :
(Signed). ...
..-*rT7X j..^;_£&t*e*wioN).
190.^. (Address)
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or Mow long at
Usual Residence Place orDeath?
How long at
Days
Where was disease contracted,
if not at place of death?
Filed
190
Clerk
•City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
$ Name and address of person giving statistical details.
II Name of cemetery.
■fjd/i
®ommoniwiIlft of lllassaqpisetts.
jP 5 /
3o.
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.)
'TZLr t/'J* 190
cSc /t v\ \Xe$U‘ r 11? £ l G’h e y
Date of Death,
Full Name of Deceased,
f 1 Maiden Name, —
J If a married or divorced '
\ woman or a widow give also C _ „ . ,
J Name of Husband,
Sex,
Age, £ / Years, ^ Months, C Days. Occupation,
* Residence { fjg: } / #/
Place of Death,
/ 01) /)
* Color, Singly Married, WidowcchcH^£tivorcedr
(^"£f r: t t
SS
Place of Birth, ^
Name and Birthplace of Father, ^ ^ ^
Maiden Name and Birthplace of Mother, ... Sx/ > jL f * /£
Place Of Burial (Give name of Cemetery),
Dated at Signature and V
on - *
‘-tv
Signature and
place of business
190 of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date
of Death,
W
died at...
Disease or Cause
j Primary,
v l
of Death, J
\ Immediate,
D.
ChJ d]^) _ _ 1 90 ^ — .
Duration,
Duration,
1 certify that the above is true to the best of my knowledge and belief.
\ 4 c-
Signature and Residence "
of
Certifying Physician, i
M. D.
Date of Certificate, “V- A
190
• Give alio street and number, if any. f Give sex of infant not named. If still-born, so state,
t If a Soldier or 9ailor in the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the flerlc of the city or town.
■1 gent of Board of Health.
RETURN OF THE DEATH
1
Form C.
No.
r *
of 'IHassacbusetts.
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.)
Date of Death, /SOCK/ cA J 190 A
Full Name of Deceased, f (Da4. fJu
If a married or divorced
woman or a widow give also
1 Maiden Name,
j Name of Husband,
Sex, Color, -Single, Married,
Age, Years, y ""-Months, r ’Days. Occupation, (/ '[ ^ Y y
* Residence {“so state fun?:} JLCUr
Place of Death, U £7/ f^J /j£l / /
Place of Birth, ^ -/SsC&S
n
Name and Birthplace of Father, 0/ AAlAA^^^u - r ' AS? Ci £xXAa< c/y
Maiden Name and Birthplace of Mothe^, Cd//j>AlA^ IP a A CA - : 4( '
Place of Burial (Give name of Cemetery), Sf i ^ %i' ' y)(T/
Dated at ll't S:'L f) /. — ’2. Signature and
on
mu
. . place of business 4
190 yX- of Undertaker. 1
A
PHYSICIAN’S CERTIFICATE.
/Waxy
Name and Age of Deceased,!
Place and Date of Death,
Disease or Cause j ^>r^lllaD >
of Death,} Immediate,
/9.
^n^rxjL^J
Xt-
died al
Age, Y M D.
y?2^H 2sZL I90y.
■Do Nation,
/'^cC . Duration,
1 certify that the above is true to the best of my knowledge and belief.
Signature and Residence '
of
Certifying Physician, .
2X3.0.. .
_M. D.
Date of Certificate
, 190^
f I nfint not
• Give also street and number, if auy. f Give sex of InAnt not named. If still-born, so state,
t If a 8oldler or Sailor In tlie War of tbe Rebellion, give both Primary and Immediate Cause
Countersign and transmit, to the clerk of the city or town.
Ayent of Board of Health.
RETURN OF THE DEATH
Form C.
(Jammflttbxeallfr af lllassaxjwsetis.
Jo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
) (Old (&ICUAJL (ml rn \ jeuj
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Date of Death*^-- C4/14J;J Sd " 190 (x /
Full Name of Deceased, *, J^^dV, (Otvp
{1 Maiden Name,
If a married or divorced 1
woman or a widow give also f
J Name of Husband,.
Sex, °?w Color, dO Single, Married^ Wfdowod or Divorced,
Age, Years, dfy Months, 2e2^Days. Occupation, r' ‘ ^ OX ^ '
/^7i t , — ^ .
* T?p<3irlpripe ( If out of town, ) 1 ( if /) /J) O O j
liesiaence , aiso state fully. } •• i/VC r l
Place of Death, 2*/^ C2&
Place of Birth, (J'/'l/flOOi JdjfjLj /dOoYyl/O
Name and Birthplace of Father,
Maiden Name and Birthplace of Mother*.... OY.J-OzAs /pOfA^f/T-'Z) -&&£)... 0 oods
Place Of Burial (Give name of Cemetery), ^^(dd^OXjOfd/ dddtJorn^ vSd OH
PHYSICIAN’S CERTIFICATE dF THE CAUSE OF DEATH.
Boston, 'J d •d 190 *d ^
Nam,e and age of deceased l, 7T. Age, 4# ijelars.
Bate and, place of death f . / </ df
j Chief cause, ^ 6/L<S~l // /
do- C-CO C d d
Date
on Ol\d,td.dd. JLO..
ignature and
y place of business
190 'f' of Undertaker.
ytd
Disease
Duration
Contributing cause,..
j Chief cause,
| Contributing cause,
I certify that the above is trice, to the best of my knowledge and belief.
Name and residence
M T).
of physician, ) /y /? n
*lf 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 , eacept during the months of June,
July, August end September, when the office will bj closed on Ssturdsys st 12 M. ; Sundays, 10 A M. till 12 M. ; Holidays, from 10 A M. till 12 M. ; other
days, from 9 A.M till S P.M.
RETURN OF THE DEATH
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Form C.
Cammotthiedtfr d IJlassarfensetfs.
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.)
' UAtJ / " 190 44
Date of Death, \ C ’'^44 - 190 -^"n
Full Name of /deposed, (/ Gy? 'QJuyyyts A JA
f ) Maiden Name, TWoms Qy SAM yyyuyjj
J If a married or divorced 1 /! S /y \ ~/y
I woman or a widow give also ( __ „ „ , „ // „ / , y . /. , fitn
f J Name of Husband, A.yt fV
Sex, Color, ')/tr -Single, Marr-iod, Widowed or Divorood,
Age, a Years, — Months, C"" Days. Occupation,
* Residence {KtafeS}.. Qfi CXl4Z$^ A
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Place of Birth,
Name and Birthplace of Father, tMjyZy/u^
Maiden Name and Birthplace of Mother, fy& *L
Place of Burial (Give name of Cemetery), 04^ C^AJJAAa -Vo (fifyiyyA.
Dated
on
k^J uAl^. ./....c..::
Signature and
. j place of business
.190 of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! Afire, 8(> y . ^ M. ~ D.
Place and Date of Death, died at//* . A 190V.
Disease or Cause ) Prima^’
of Death,! | Immediate,
(S .
Duration,
Duration,
1 certify that the above is time to the best of my knowledge and belief.
<y?, ‘
Signature and Residence '
of
Certifying Physician.
Date of Certificate,
M. D.
3 //..
190/4
• Give also street and number, if any. f Give sex of inlsnt not named. If still-born, so state.
J If a Soldier or Sailor in the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit, to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
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Form c.
Xo.
h
dtammontedtfr d lltassatlps,etl$s
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death,
Full Name o(
If a married or divorced
woman or a widow give also
) Maiden Name,
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
uJa.4 // " 190 ¥
j Name of Husband, 'Ji/qAa
Color, A- Married, Widowed ™ r>hTnTr0ri
Age, Years, S/ Months, (^^^JDays. Occupation, C
* Residence { ® { .. Or tXdJUrfz> *}pUts£J;
^ Jr 'A" . — ,
Sex, \J/
Place
of Death, fwdsfzt/t/
Place of Birth,
Name and Birthplace of Father, t V &/f2
Maiden Name and Birthplace of Mother,, fJ/yi/J \ tcyi <f (n/v^- lA^/nAsiAs
Place of Burial (Give name of Cemetery),
/J2 « .....190 </
A Signature and
place of business
of Undertaker.
1) t
J !)
PHYSICIAN’^ CERTIFICATE.
Name and Age of Deceased,! , Age, ^ Y. //
Place and Date of Death, died at [l^V fy/M j •> SjL'L 190 V
l%. ,, ( Primary, X D urat i on , ? AVtcJlAf^A
Disease or Cause ) / is ^
of Death,f j Immediate, 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
icate, ^
M. D.
Uf<
190 y*
• tiivc also street and number, if any. f Give sex of infant not named. If still-born, so stnte.
{ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Iminediaie Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
•‘££Sit
V,
%
4
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
*
FULL NAME
Place of Death *.
Date of Death
RETURN OF A DEATH
Age days
Registered No.
STATISTICAL DETAILS
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVALI
UNDERTAKER
SS./Pt
DATE OF BURIAL
A
ADDRESS
COLOR
SINGLE, MARRIED,
WIDOWED, OR
|IV(JRCED
MAIDEN NAMEt
^ r
HUSBAND’S NAMEt
BIRTHPl ACEt
^
NAME OF y * -
FATHER^2^^ <
BIRTHPLACE
OF FATHER! jfT
^ y?
1 MAIDEN NAME
°F “°THE"
<%/c 9lT7^L.
BIRTHPLACE
OF mother! // /
PHYSICIAN’S CERTIFICATE
I HEREBY ^JERT^Y that I attended deceased during last
|l9^, Jo ..6.
illness, from |l9|a to 0 1/ 190 ,
that to the best oT my knowledge and belief death occurred on the
date stated above, and that.the CAUSE OF DEATH was as follows:
Primary :
bove, and that.the CAUS
JJj bJ,
. (duration)..
Contributory :
. (duration). DAYS
*^.vy I M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or
Usual Residence.
How long at
Place of Death? Days
Where was disease contracted,
if not at place of death?
Filed
.190
Clerk
•City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow.
J State or country) also city, town or county. If known.
$ Name and address of person giving statistical details.
II Name of cemetery.
CITY OF BOSTON. COMMONWEALTH OF MASSACHUSETTS.
CITY OF
RETURN OF A DEATH 1904. BOSTO
saao.
Xfrfri! ■m’0'
full NAME Edvzard G Parker Registered No 6220.
Place of D...h i Boston ;'a™ General Hospital
and Residence )
27 1904 A Cf 6 years months days.
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX COLOR | SINGLE, MARRIED, WID., DIV.
mal ft whi t. «=* 1 qi n^Tfi
1 HEREBY CERTIFY that 1 attended deceased during last illness,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:) Cancer of ..S.t.Q.m.ac.k..A...mo.s
Maiden Name — •
Husband’s Name
Hvannis Mass
(Duration) \
Birthplace
Name of Joseoh C
Birthplace Hyannis Mass
contributory:) Gastro Enterostomy
(Duration) )
8 ..days
Maiden Name Arabella Harris
Birthplace Hyannis Mas3
P A Washburn Jr m.d
BnokkfteDer
(Signed)
July 2^04
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recon
Residents.
Place of Burial Mass Crematory Ashes to Hy
Mas s
Undertaker Lewis Jones.. & Son
annilSResidence?®..?.r.P.S.P.®P..tf..AT...^iXJ.tlir.O.P
Filed July.... 3.9.
Registrar.
7 >
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4
H
Form O.
{Jommflnbxe&llfr of
yj/.
<Z o
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death,.
Full Name of Deceased,
FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
^ 190 %
If a married or divorced
woman or a widow give also
1 Maiden Name,
Sex,
Single, Married, Widowed or Divorood,
O'
J Name of Husband,
Color,
Age, c=2~3 Years, v5 Months, ^ Days. Occupation,
* Residence {Kutefuu?:}.. ^ Gs^C, ^
Place of Death, r )fcJLy Otr-C...
Place of Birth, <^X '<plx > ’■ ry
Name and Birthplace of Father, cf . > '0~( ^ .
Maiden Name and Birthplace of Mother,. CxCi. c-c / ^ i.
Place of Burial (Give name of Cemetery;,
tylA.A.fy'f.X' Signature and ( a(
/) « ' , /• place of business ) X * / / C
-190 V of Undertaker. ( X/jfG. SS? ^7
Dated at.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! Age^J^-Y. ^ M. T)t
died at_. Av< 190
Place and Date of Death,
Disease or Cause I ^>r^tLiar.x >
of Death,! / Immediate,
lAsb&vc kaJats-jx* lo Lw^o Duration,
... Duration, ....
I certify that the above is true to the best of my knowledge and belief.
• Give also street and number, if aDy. 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
M
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COMMONWEALTH OF MASSACHUSETTS^
C^}/ 2.^-L *
RETURN OF A DEATH
FULL NAME Registered No
Place of Death *.
Date of Death - r. Age .'2 „...>
.years. .
.months .
.days
STATISTICAL DETAILS
SEX COLOR
t> 1
4ARRIED,
iN'ILIi.iliii'i LI, l-TTT'
DM*M££J2-
MAIDEN NAME
HUSBAND’S NAME t
BIRTHPL ACEt
NAME OF
F4T"E^ - • Vlfn^M
tf-tAA /vUrw.
BIRTHPLACE
OF FATHERt
'ke.
MAIDEN NAME
OF MOTH.
BIRTHPLACE
OF MOTHERS /O
ii>c
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL!
DATE OF BURIAL
- (7
190 .
UNDERTAKER
ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from 190 to 190 ,
that to the best of my knowledge and belief death occurred on the
date stated above, ai^d that the CAUSE OF DEATH was as follows:
•:
Primary :
.(duration) .DAYS
Contributory :
(Signed)
-V-. (duration)
. i -ML. . .
(duration). DAYS
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or
Usual Residence.. KV.
Where was disease contracted,
If not at place of death?
2^
.4? l9ofy
' 6 i. t : .4 ^
“ ^ Clerk7
—
* City or town, street and number, if any, If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If in a Hospital or
Institution, give its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, {.own or county. If known.
§ Name and address of person giving statistical details.
Name of cemetery.
l
CITY OF BOSTON. COMMONWEALTH OF MASSACHUSETTS.
CITY OF
RETURN OF A DEATH 1904. BOSTO
FULL NAME Arthur D Allen Registered No .6410
Place of Death ) Boston Car n.ey Hospi tal
and Residence )
Date of Death A.Ug..l 1904. Age 29 year, 8 mentn, 24 -day,.
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
male white married
1 HEREBY CERTIFY that 1 attended deceased during last illness,
from 1904 to 1904,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
53' j Pul— -Embolism 3 min
Maiden Nam©
Husband s Name
Birthplace .b.QJHe.r.Y.l-L-Lft -M&SS
Name of r QAr-ra U
Father .USOrgS-LL
Charlestown Mass
Contributory:) Pleurisy with effusion
(Duration) j
17 days
Maiden Name Marion Hauchett
of Mother
Birth pi ace Lexington Mas.s.
(Sianed) W A Thompson M.D.
. Laundryman
August. 2904
Occupation
SPECIAL INFORMATION from Ho»pital«, Institutions, Transients, or Recent
Residents.
place of Burial Cambridge Cem Cambridge
Undertaker J°bn EROUke
Usual Residence ’^throy, MaS8
Filed AUgUS t... 4 1904.
— " Registrar.
Form C.
®0mmon£omlt(j nf lJtassar{Msett&.
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death,
Full Name of Deceased,
(FILL OUT WITH INK- ALL NAMES TO BE IN FULL.)
t / ( < sy 190 s/
If a married or divorced
woman or a widow give also
1 Maiden Name,
j Name of Husband,
Sex, 9- Color, 9S
Age, ^<-2 Years, Months, — Days; Occupation,
Single, Married, Widowed or Divoreed,
r* * a ! rjf
* Residence {iLosutefuu?:}
Place of Death,
Place of Birth,
Name and Birthplace of Father, /*(
Maiden Name and Birthplace of Mother, (G?.
Place of Burial (Give name of Cemetery),
' | / place of business
190 VA_ of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,
Disease or Cause \ ^mar.v ’
of Death,! j immediate>
SICS AN’S CERTIFICATE.
" ^ “ ' 1st
diedat t
190
.... Duration,
... Duration,
1 certify that the above is true to the best of my knowledge and belief.
T , ^ m D.
Signature and Residence '
of
Certifying Physician.
1 190 li
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 tlie War of the Rebellion, give both Primary and Immediate Cause,
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
Form C.
No.
Cammonbxealtfr of lllassaxl^usetls.
Qam%
f
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.)
Date of Death, uA '5 V 190
Full Name of Deceased, (/
( 1 Maiden
Name,
If a married or divorced \ • , y
woman o, a widow <■». ,*o J QjJAtMJ QZjt.
v <n-
Sex, Color, yy -Single, Married, Widowed or Divorced,
Age, S‘ Years, (~/~ Months, / <0 Days. Occupation, (
* Residence {Kafefu^:} A^^c/y o yUtf^la
Place of Death, A /yc^ZL..^0
Place of Birth, A?
Name and Birthplace of Father, A wjA , /de^tf^uol'
Maiden Name and Birthplace of Mother, . A ^ vy 2^<
) Af)\ .
A/j:u.a
C^Adj J& 190 Pof Undertaker. [ // ^ V/^* V? < ^
PHYSICIAN’S CERTIFICATE.
Place Of Burial (Give name of Cemetery) fiuaal
Dated at. Qjr r/i/i. /{J/MAhj p
Signature and
on
Name and Age of Deceased,!
Place and Date of Death,
Disease or Cause ) Primary .
of Death, t I lmmediate;
Qy-X^LC.
Age,.Z<£r Y zi M. X<Z.D.
190 (J
Duration,
Duration, %on^UruL^<0
I certify that the above is true to the best of my knowledge, and belief.
Signature and Residence
of
Certifying Physician.
Date of Certificate, 19C^.
• Give also street and number, if any. f Give sex of Infant not named. If still-born, so stnte.
t If a Soldier or Sailor In the War of the Rebellion, give both Primary and Immediate Cause.
_M. D.
Countersign and transmit to the clerk of the city or toirn.
Agent of Board of Health.
return of the death
COMMONWEALTH OF MASSACHUSETTS
bC>o>/j
FULL NAME
r,h-i tk
Residence
*L • J^CLCs/l:.
CtM //
REVERE.
( CITY OR TOWN.)
^/7L^5nL^).. Registered No
Date of l
Death 1
190
T
months / days
STATISTICAL DETAILS
PHYSICIAN’S CERTIFICATE
last
I HEREBY CERTlfpC that I attended deceased ^
illness, from JLaJc*1 %J[) 190^. to . x&JM' <|..|.10 ... 190 ^C ,
that to the best of my knowledge and belief death occurred on the
date statej
Primary:'
ove^ and that the CAUSJ^OF DEATH was as follows:
VVA
ca>j
.(duration)
Cma^s#:
Contributory :
. (duration) DAYS
■ •!»*• • • • -j - •« \ uunni iw
(Signed). ..^^>^.CLJIAACSJIuVVaAJL|JL^^4LJUv^?...M.D.
.OOl^.XAddress) ...i.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? .
.years months.
days
Where was disease contracted,
If not at place of death?
Filed
* .
.29, 'ion
Clerk
*City owtown, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If in a Hospital or
Institution, give its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country | also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cem^ry.
Form C.
CXaa
IA
6
A
rm
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALU NAMES TO BE IN FULL.)
Date of Death, CJsu.y?jpAy Ay 190
Full Name of Deceased// yy?. 4. dA, & .£ dsAAAu
( ") Maiden Name, /A^P ,
J If a married or divorced
| woman or a widow give also
j Name of Husband, 1/rA t/df r
Sex. Color, jt- Single', Married, Wid^wod or Divorced,
Age, J A P) Years, / O Months, / A Days. Occupation,
* Residence { && }
Place of Death, *2 QA A C'f'J A s2,/ls..£\ iAt/'* . ffj
Place of Birth, y J^/l JVlAA^fLS ..A
'L
'sOP-
Name and Birthplace of Father, ..AZA/ tlpJ. AgZP A]AJ^-
Maiden Name and Birthplace of Mother, . y2) Cdy../2-Vt' ffSyyAA^ - A APULl
Place of Burial (Give name of Cemetery)
Dated at
&>U.
on
QkiJdMi < "«
/y
Vf
Signature and
. * place of business
.190 7^ of U ndertaker.
// AAjA&ia/M <44 aSClpiA
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! xPfyYAA^ (A fp r (AdUMja^ Age/Ap Y. V.O.... M.V 3... D.
Place and Date of Death, died at JfysAAsjA'i. drP. ’ CA^Pj -J'/- 190 A
T.. (Primary, Duration,
Disease or Cause ) n , /
Immediate, Duration, <3
of Death,J
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,
<3
,/2L IwC.
4h
• 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
return of the death
y
Htt
I
Form C.
Cbju a
/ </*>
l Hr
Commoniuealtfr 0f ^tassairferrsett^
A To.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
WITH INK. ALL
Date of Death, ( ' j/ C ^
Full Name of Deceased,
(FILL OUT WIJH INK. ALL NAMES TO BE IN FULL.)
A
If a married or divorced
woman or a widow give also
Y Maiden Name,
J Name of Husband,
Sex, 7W Color, ^ Single, Marriod, Widowod or Divorced,
Age, ("^—T Years, C^" — Months, (o> Days. Occupation,
* Residence { 5 ^TIAJQAA-
Place of Death, / ^ ' CfAAjliAAJX J?J?A
Place of Birth,
Name and Birthplace of Father, (jjmdcfj A @UaJaj^ )
an ^ r. In)
other, .
'A
Maiden Name and Birthplace of Mother, £c> /{. 9^ fL C=Pl/U f } A A, / yi A y l -dJ J... A fa)
^ 1
Place Of Burial (Give name of Cemetery),
Dated at. ...
on Q^ki
Signature and
) (&A.Ald/A.
■PH) ££ ' oTundertaket\S [ /
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! ^ Bx£r$u^ Age, — Y.r n_M. C D.
Place and Date of Death, died at / £?.. ff. 190 A
,,. rt ( Primary, liu ration, Jo..j
Disease or Cause ) J //
of Death,! j Immediate, — — Duration,
1 certify that the above is true to the best of my knowledge and belief.
, YU- i.
Signature and Residence V *"■
of <
Certifying Physician. /
Date of Certificate
O'
, o t 190 y
M. D.
\l[K^AA
• 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 Immediate Cause.
Countersign and transmit, to the clerk of the city or town.
igenl of Board of Health.
RETURN OF THE DEATH
r>
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Form C.
Cammontallfr nf Stassarfriisetts.
u\AA'-%
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT
Date of Death
Full Name of Deceased
d^lTH INK
^ c2 d ” 190
CC , ,
cuu^
ALL NAMES TO BE IN FULL.)
U
If a married or divorced
woman or a widow give also
1 Maiden Name,
J Name of Husband,
Sex, 7tv
Color, J) Single, Married, Widuued er Dihiuiu.il,
Age, Af Years, Months, Days. Occupation,
* Residence { ^ }
Place of Death, y y m/uAQiJy L()/p}ilAp
Place of Birth,
Name and Birthplace of Father, ,r
V
Maiden Name and Birthplace of Mother,
Place of Burial (Give name of Cemetery) . /) a
O hi
Dated at
on I
fVX y^/L-p h?yt- y yy
oC
2i^ 190 5^-— 8 ii jFOJPAnm*
PHYSi CLAN’S ^OERTIFB CATE,
Y.
M.
D.
Name and Age of Deceased,! \ Age,..
Place and Date of Death, died at yyjis). ..cy.y^.. <2.a. 1 9o y
t.. ri ( Primary, Duration,
Disease or Cause ) J //A /i /f
of Death,! j immediate, Duration, /
I certify that the above is true to the best of my knowledge and belief.
y
Signature and Residence
of
Certifying Physician.
M. D.
Date of Certificate,
• Give also street and number, if any. f Give sex of infant not named. If stillborn, so state,
t If a Soldier or Siilor in the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or tonm
As/.. .AL—
Agent of Board of Health.
No.
return of the death
FULL NAME.
Place of Death )
and Residence )
Date of Death
CITY OF BOSTON. COMMONWEALTH OF MASSACHUSETTS.
CITY O
RETURN OF A DEATH— 1904. BOSTC
Eliza..H©.aM Registered No 7-01-9
B.o.s.t o.n .Mass. • ... .Horn., . ... Hasp. i.tal
Aug 21
1904.
Age 7P. years .7. months 5. d.ys.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
female. wM.i.e. widowed,
Maiden Name
Husband’s Name Wi.ll.taja...He.al.d
Birthplace I s.l.e_..of ...Jer.a<2y....Gr...
Father°f - ThOmS.
ZW&l England.
“I&lrr. Annie Sherwood
of
Birthplace
of Mother
England.
Occupation non©
Informant
Place of Burial Worcester Mass
or removal vr?r.M.
Undertaker Horace.. R...Qr.an.e....&....C.o.
?....weeks...&._2.. ,.day.s..
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from 1904 to 1904,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
8X25= j
Contributory :
(Duration)
Wm 0 Mann
(Signed) M. D
Aug 21
904 .
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Usual Residence P-.?. . . . .^nd© Till 1.1 .. . SI). . . W.in .t lU".Qp. .
Filed Aug....24 1904.
A true copy.
Attest :
Registrar.
physician's cert ificate of the cause
Form C.
JVc.
®ommontu£;tltlj of Itlasearijusetts/
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death,
Full Name of Deceased
(FILL OUT WUTH INK. ALL NAMES TO BE IN FULL.)
c / "
190
Of/ ' QA/obsLA
If a married or divorced
woman or a widow give also
<r^
1 Maiden Name,
J Name of Husband,
Sex, Color, Single, Mamod, WitUwml or Divorced,
Age, Years, Months, / Days. Occupation,
* Residence Or
/O
Place of Death, ___
Place of Birth, CfALs/ /- jVy ’ -
r, Ux/'
Name and Birthplace of Father
Maiden Name and Birthplace of Mother, &uIhA Cb,
>, AAcAitlvvbjo
Place of Burial (Give name of Cemetery),
CZ:1/IAAAX^u^ AZP.
. *- place of business J./ . r-p f
90 of Undertaker. [ / Q AJy JA'Pl^A
Signature and
place of business
P HYSLplAN’S CERTIFICATE
Name and Age of Deceased,!
Place and Date of Death, died ^t
w ( Primary,
Disease or cause J J
of Death, { J Immediate,
I certify that the above is true to the best of my knowledge and belief.
C7LtZZ*y
Age, O'. Y. y M./^ D.
(g/Jy Jzr siA
Signature and Residence '
of
Certifying Physician. .
M. D.
Date of Certificate,
ZZ
190^
^
• Give aleo street and number, if any. f Give sex pf infant not named. If still-born, bo state.
| If a Soldier or Sailor in the War of the Rebellioit^ive both Primary and Immediate Caiiee.
Countersign and transmit to the clerk of the city or town.
....C/s <
Agent of Board of Health.
return of the death
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Form c.
Cammoniuealtk ai IJlassarlpsetlB.
/TV
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.)
Date of Death, '' 190
Full Name of Deceased^ ^jPAviMlcIs CV ,
If a married or divorced
woman or a widow give also
1 Maiden Name,
j Name of Husband,
Sex, Color, Single, Married, Widowed or Divorood,
Age, r " — Years, ^ Months, f^^^-Days. Occupation, ^ —
* Kesidence
Place of Death, /'/% LsUj2^l
Place of Birth, 72ACl^>
Name and Birthplace of Father, Q/jdtUa^uL (2t,
Maiden Name and Birthplace of Mother, sul / /3te/XyL
Place of Burial (Give name of Cemetery), ....
X. Signature and ( cb
si / /?A#
Dated at
on ....
z/lJQjL j... 190 J4
Signature and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! i (2X ' \y. y?„ m. ,c^d.
lied at CX.A.< 190 ££
Duration,
Place and Date of Death,
Disease or Cause j ^>r^ln,ulv »
of Death,! )Irame diate,
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,
_M. D.
190
y
• 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 Immediate Cause.
Counlereiyn arid transmit to the clerk of the city or town,
/A
— -
A yen l of Board of Health.
RETURN OF THE DEATH
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[n-’02.37-LM.J
Permit No.
' V
RETURN OF DEATH.
(If a married or dmrreed woman give maiden name, also name of husband.)
Sex,
a
Color, Condition,
i, White, Black, Mixed, Chinese,
IndiaD, etc.)
Age, f A* $ Years, ff* Months, SDays. Occupation,
Residence, SJL Ward,
Place of Death, /A T
Place of Birth,
C&ccsrd:
Z ZZ
(State year, month and day.)
Date of Birth, ^ Sff & £
Name and Birthpla
of Father, )
Maiden Name and;
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Place of Interment, 'f//c *-*- tN' Ce^t *
tPZ /. / ZI>L
7/ si A /? ACndertaker.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
Boston , ^ ^ 190
-C Age, ut£. years.
AP 7 A <2. (. & i
n /S c A
Name and Age >
of Deceased , J
Date and
Place of Death
f Chief cause,..
Disease
( Contributing cause,
[ Chief cause,
Duration
( Contributing cause,
I certify that the above is trum
Name and Residence )
of Physician,
’If an institution, state how long an Inmate and previous resilience.
Pgejuid belief.
M.D.
>
L
Form C.
Commontomlth af
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
Maiden Name, ) If m^<l?Sd?wed i
Husband’s Name,
/ * (FILL l.
Sex^^5??^'Col()r,
, .190^^4 Age,' — Years, ^ Months??^^ ..Days.
Occupation,^
Single, Married, Widowed or Divprced, . v^upnuu,"" - • «
♦Residence, ) ll°0a^tc fun"’ j t
Place of Birth,
i
♦Place of Death,
Name and Birthplace of Father,
Maiden Name and Birthplace of Mother,
Place of Interment, (Give name of Cemetery), PT ^ /
Dated at
on
*j£-
Signature and
place of business ,
of Undertaker. ( / ^
PHYSI
S CERTIFICATE.
Name and Age of Deceased, f
PI ace and Date of Death,
t~v* n ( Primary,
Disease or Cause 1 J
of Death, J J Secondary>
Age. — Y. yT. .M^f D.
■
\ Duration,
Duration, / 0
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
of
Certifying Physician.
M. D.
of Certificate,
and number, if any. f Give sex of infant nob named. If still-born, so state,
ailor 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
02
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03
Place of Death I
and Residence )
Date of Death
CITY OF BOSTON. COMMONWEALTH OF MASSACHUSETTS.
CITY O
RETURN OF A DEATH-1904. BOSTC
_Er.e.dari.c.k...W, tV.alsh. Registered No 7 .4.0. 6.
...B.o.s.to.n., Baptist. Hosp. Parker Hill..
.S.G.p....4.j. 1904. Age .4.6. year* montn* dayJ
SEX
STATISTICAL DETAILS.
COLOR
SINGLE, MARRIED, WID., DIV.
...M. ,W.
Maiden Name
M.
PHYSICIAN’S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness
from 1904 to 1904
that to the best of my knowledge and belief death occurred on th<
date stated above, and that the CAUSE OF DEATH was as follows
Husband’s Name
Birthplace Bociiester ,K«Y
Primary
(Duration)
Urinary.. ...ex.tr.aYaaa.t.ian....
from ruptured ur.e.tiii a
Name of
Father
Birthplace
of Father
Maiden Name
of Mother
Birthplace
of Mother
Occupation
Informant.
..Fr eder ick.. W... ...Walsh..
..England
.Enma...Wi^nall
..England
.Publisher
(Signed).
.0,. E,. Johnson m.d.
.S.e.p....S. 1904
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of Burial .
or removal Winthr.op....Cem.,....Win.th.r.o.p.
Undertaker S-Uimer ElOyd
Winthr op
Usual Residence W.i.n.thr.ap.y3arlle-t-.t---Rd
Filed S ep -.8., 1904.
A true copy. x7
Registrar.
©(DSTdDNIA.
Form C.
(lommontaltfr of litosar^setts*
T
No.
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.)
If a married or divorced
woman or a widow give also
Date of Death, £ 190 (£
Full Name of Deceased,
1 Maiden Nai^e,
; >
J Name of Husband,.
Sex, Color, } 5 Single, Mamriod, Widowed or Divorced, -
Age, ( Years, CX^__Months, ^3 Days. Occupation, (
* Residence fun": } Jf "
Place of Death,
Place of Birth, /r "
Name and Birthplace of Father,...
Maiden Name and Birthplace of Mother,
Place of Burial (Give name of Cemetery)
r
Dated /at .^.Jf....C'1/l/^dyi^^ A —
<55..... L 190
on
WOd
Signature and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! ^ Age, Y M 1 D.
Place and Date of Death, died at 'vj 90 f~.
Primary, Duration,
Duration,
Disease or Cause
of Death,!
Immediate,
I certify that the above is true to the best of my knowledge and belief.
* Give also street and number, if any. f Givo 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
-< ~ _
Agent of Board of Health.
RETURN OF THE DEATH
Form C.
®0mm0itbxeaIl(j 0f l|tassat{msetig.
•... , $ /
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.)
Date of Death, £ ^ 190
Full Name of Deceased, Xj). ] { ' /O^Pl/lAz*
If a married or divorced
woman or a widow give also
'j Maiden Name,
f —
) Name of Husband, , —
Sex, Color, Zki Single, Married, Widowed-or Divorocd,
Age, — Years, Months,
* ■RpQiHpnop ( If out of town, )
iiesiuence j also state fully< j
Place of Death,
Place of Birth,
Days. Occupation,
C
'aAA.
Name and Birthplace of Father,
Maiden Name and Birthplace of Mother, ..
Place of Burial (Give name of Cemetery),
Dated
on
C 190
Signature and
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased, f Age,
Y.<
M.
D.
Place and Date of Death,
died at
Disease or Cause ) ^>™nary>
of Death, t j Immediate,
f 6 • 190 +h.
Duration,
'.A... Duration,
1 certify that the above is true to the best of my knowledge and belief.
• 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 Immediate Cause.
Countersign and transmit to the clerk of the city or ioum.
- ^6^C> </<? vt^£^e^C_.
Agent of Board, of Health.
RETURN OF THE DEATH
4
4
1
Form C.
Cammonfomllfc nf Stassarijpsetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
W7 (FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Date of Death, / 0 ,f 190
Full Name of Deceased,
t 1 Maiden Name,
If a married or divorced 1
woman or a widow give also
K
j Name of Husband,
Sex, Color, Q£ Single, Married, Widowod op-Diverood,
Age, ^ — Years, ^s^^Months, ^ Days. Occupation, C
* Residence { ® |
Place of Death
, (o£ &QsUJklu^ Up&J -
Place of Birth,
//
//
P
Name and Birthplace of Father,.. VJr~
Maiden Name and Birthplace of Mother, . AOcppu — Of,
Place of Burial (Give name of Cemetery) S AP '
Dated at
on...
'..Pi/
./...
Signature and
l t / place of business
.190
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! /0(^/!AOJ Age,.p^PY. A M (?. D.
Place and Date of Death, died at. 190
T. . „ ( Primary, Duration,
Disease or Cause J
of Death, J j Immediate>
Duration,
I certify that the above is true to the best of my knowledge and belief.
• V -^> — '
Signature and Residence '
of
Certifying Physician.
...M. D.
Date of Certificate,
) \ b
tX^J
190^ .
• Give also ntreet and number, if any. f Give sex of infant not named. If stillborn, bo state,
i If a Soldier or Sailor In the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or town.
. (^is. . A. . .
Agent of Board of Health.
RETURN OF THE DEATH
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/$&?***. CITY OF BOSTON. COMMONWEALTH OF MASSACHUSETTS. ?"
-. CITY Ol
RETURN OF A DEATH — 1904. BOSTC
FULL NAME Ar ,t.hu r . . . M . . . . .L&C.V. Registered No 7510
CV} f V
plac,e°f Death ( Boston , Children's. Hcsp. "
and Residence J > P * y' ’
Date of Death S.e.p.e.11-, 1904. Age years 4 months .4 days
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
M W. S
1 HEREBY CERTIFY that 1 attended deceased during last illness,
from 1904 to 1904,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows*
Primary:) Atrophy 4 m03
Birthdace Boston
(Duration) J w
Faather°f J 81116 3 Racy
3f,!?S" Brookline
Contributory : |
(Duration) j
^faM*tnL^ame Catherine Gilhride
Birthplace ^ ,
(Signed) R .. .S. Row! and M.D.
..Sep. ►11. y 1904
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
r: aCre mo vBa1 \ .'.a ' Br o.Q kline y Ho.ly ho .o.d . ..C en
Undertaker Jai»©S J • • 0 * Dfty
Brookline
Usual Residence W.in.t-hr.Q.p.
Filed 5@p-.12, 1904.
' <C4M7?Z
Registrar.
iU.j
Permit No..
' *■
RETURN OF DEATH.
BOSTON MASS.
Date 01
Name in full, ..
Sex,
(ff^uruz-r^—
l woman give maiden name
Color, //£/..
...Condition,.!
(White, Black, Mixed, Chinese,
Indian, etc.)
(Single, Married, Widowed or
Divorced.)
Age, . (J O . Years, Months, Days. Occupation,
Residence,... Crv* y&wv< &
u /Ward ,
re-
place of Death,
r ^ * * r (State year, moutn ana aay.;
Place of Birth, £ .. Date of Birth, /'J; < ^
Name and Birthplace j InJ
of Father, j
Maiden Name and )
Birthplace of Mother, \ - /Jf N ' f A
Place of Interment,
Undertaker.
Disease
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
Bost&j, /C — J 90^.
.. c c Age, ears.
| Chief cause,
Name and Age )
of Deceased , p"f
l
Date and
Place of Death,
{ Contributing cause,
Duration
( Chief cause, CfT C+a^v
inn. <
\
Contributing cause,.
tr~-
C't4y£'<rfy.
I certify that the above is true to the best of my hnowledge and belief.
M.D.
JA/Lma
Name and Residence I
of Physician, I
•If an Institution, state how long an Inmate and previous residence
Permit No. /.
RETURN OF DEATH.
BOSTON, MASS.
Age, 2.7 Years, Months, Days. Occupation,
Residence, Ward,
Place of Death, s' _ Y/R YA jrY'V
Place of Birth, y'Kj'f'yYfr'i- r/'YM&ZT!
Name and Birthplace 1 ( * L '^A.Y^r..
(State year, montli and day.)
Date of Birth, acAN^jr-ysyi
of Father, )
Maiden Name and
Birthplace of Mother
Place of Interment,
ctsZ, '
Undertaker.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH
/
Name and Age )
of Deceased, ) '
Date and ) . ;£. Z ^
Place of Death,* j f
Chief cause,.. &2<-^4Lc. ,t.»C i4L
i90f/„.
//tfe, 2^. years.
Disease
I
( Contributing cause,
*S~ „
| Chief cause, ....
Duration q
( Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
M.D.
Marne and Residence I
of Physician, )
•If an Institution, state how lon^ an inmate and previous residence.
' "
(\
t
^ r.
£
]
• • - ’
Form c.
CQmmflttbxealtk of
/ v
V MT
<U‘ /
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.)
Date of Death, A A1/' " 190
Full Name of Deceased, aO
{) Maiden Name,
If a married or divorced y
woman or a widow give also
Sex, Color,
Age, ^ Years, A Months, A ^ Days. Occupation, f' ~
* Residence {S^totoSS?:} AtZeA . APt
j Name of Husband,
Single, Married, Widowod or Divorood,
p
Place of Death, X A > ^/ZatP^O. /&) Lasla./
Place of Birth, Ao OuyA
Name and Birthplace of Father, AAf/ ft/l4Ay fjy pA/yAyL
Maiden Name and Birthplace of Mother, e=P7yVt (^-/yrt^cly r=
Place of Burial (Give name of Cemetery), ®Jg4/1A*A
Dated at. Signature and ( is iA/l/l/tAALAy ^^AA4fkf;.£Ay..
4k, /TTT7 „ /-o // c/ Placiof bU8i“efls i / Qy
on
YsjQ&MA'L&Ss... J&L ..190 </
place of business
of Undertaker.
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,
Mre,^ Y.j3_M., /fj).
Disease or Cause | ’
of Death, | j jrame(jiate>
died at. / A /Ao>/}yFZ/l- /&) Ak)/^f@ A tfL^A ' 190 £-4
puration, 7 yy±f
Duration,
I certify that the above is true to the be
my know ledge <da»*Hbelief.
Signature and Residence
of
Certifying Physician.
M. D.
Date of Certificate,
• 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 Immediate Cause.
Countersign and transmit to the clerk of the city or toam.
Agent of Board of Health.
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KCJ 84^
Permit No.. .
' *
RETURN OF DEATH.
BOSTON, MASS.
if O
/?
Name in full,
(If a married or divorced woman give maiden name, also name of husband.)
(Single, Married, Widowed or
Divorced.)
Sex, Color, .tgy AA Condition,
(White, Black, Mixed, Chinese, (
Indian, etc.)
Age, ./fr/./CY ears,..." Months, zz.. Days. Occupation,.
Residence,.. Jy Ward, N
Place of Deal h, .ClCf^/(A f^JL. J f t L <-
(State year, month and day.)
Place of Birth, of Birth, / ^ CTJ?.
Name and Birthplace ) C<^J> /<_
of Father,
Maiden Name and ) \
Birthplace of Mother, 3 ^
Place of Interment,.. s ft/
Undertaker.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
Boston
, jfL .190..M (
and ) Vj^ Q_yP yd X -f/C
Name
of Deceased
Date
Place of Death,* j
f Chief cause,
Disease -<
years.
‘IaJLc^z*—
Duration
( Contributing cause,
( Chief cause, ^ A *
( Contributing cause, vv* W—A *
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) 1 \. V v V
of Physician, { \ M.D.
’If nil Institution, state how long an Inmate and previous residence.
Form C.
/]• Ji
\l* J
ol J|tassaf|ws*tts.
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
ir ILL U (
Date of Death, (PiX^fep
Full Name of Deceased,
If a married or divorced
woman or a widow give also
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
" 190 t/r
1 Maiden Name, /" ' ^
J Name of Husband, (
Color, 'J/ Single, M«H?*4ed, Wid-ewcd-or Divoreeth
Sex, y foy
Age, ^ Y Years, Months, — JDays. Occupation, ' )--'l 'C. O, '_ J d i (J-t ft
* Residence { } . &~/nA'/ /3 O V
Op'-Tyt /§> *- ^
Place of Death,
Place of Birth,
Name and Birthplace of Father,
Maiden Name and Birthplace of Mother,
Place of Burial (Give name of Cemetery),
Signature and
place of business
190 of Undertaker.
/ ^ ydl/AP J
Name and Age of Deceased
Place and Date of Death,
PHYSICIAN’S CERTIFICATE.
,t ^ Age, -27 Y. M.CN.D.
died at <S^Ctyf 190
... ~ \ Primary, — Duration,
Disease or Cause ) ) ( H ' \ 1
of Death, % j Immediate, 1 h^^L. Duration,
I. ^ J
1 certify that the above is true to the best of my knowledge and belief.
Signature and Residence V
of 1
Certifying Physician. /
1) 'l/lUAy
M. D.
Date of Certificate,
• Give also street and number, if any. f Give sex of infant not named. If stubborn, so state,
t If a Soldier or Sailor in tiie War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or town.
[gent of Board of Health.
RETURN OF THE DEATH
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Form C.
CommflnkealtJj ai gtassacjmsftts.
s* 2 JL *
Xo.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death,
Full Name of Deceased,
") Maiden Name,
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
y " 190
If a married or divorced
woman or a widow give also
J Name of Husband,
Sex, 22k Color, Single, Maswed, Widowed of Divurced,
Asre, « 3>j Years, r Months, — Days. Occupation,
Months^P^ — - Days. Occupa
* Residence { ^LS^tafe fun?.’ } ■ 0?J~'O~zA 7
Place of Death,..
Q
7 ? / rt'-Jyl
Place of Birth,
Name and Birthplace of Father,.
Maiden Name and Birthplace of Mother, '
Place of Burial (Give name of Cemetery), .
Dated at_ Signature and (
/n?/r/ct. , .a.?. -'i. ...» '/ Tvzsr { /e
on
Name and Age of Deceased,!
Place and Date of Death,
Disease or Cause j -Pr™aD >
of Death, t j immediate,
PHYSICIAN’S CERTIFICATE.
< JXdlltyA. Age,uJ/..Y.5' ..U.CS J).
died at
.S&TjZl 'J^.J^.j2l/)dA£d^
Duration, ...
1 y. 1 ^nlyy\ tj Vh^yf^ Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence *
of
Certifying Physician. ,
or
M. D.
Date of Certificate
, m. i &L
190
Y:
• 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 Immediate Cause.
Countersign and, transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
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Form C.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death,
Full Name of Deceased,
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
ft ft 190
Aj
If a married or divorced
woman or a widow give also
} Maiden Name,^
Name of Husband,
, 7U
Sex, pl/ly Color, y/ft Single, Mamed, Widowed Piv^mH,
Age, 'ft'O Years, ^ Months, — ''Days. Occupation, t ftft) dftftftft/s-1
* Residence { afso^tafe funy.’
Place of Death,.
Place of Birth,
Name and Birthplace of Father, .
Maiden Name and Birthplace of Mother,
Place of Burial (Give name of Cemetery), ...
Dated at. jo
on
Signature and ^
(l’t;/<fJ.Lc sj' 190 of Undertaker. ^ /ft ^ fe/Jj/
PHYSICIAN’S CERTIFICATE.
Name and Age of Deceased,! A-P i AfJ S ft Age,yO?^ Y. M..C /S>.
Place and Date of Death, dietlaO /ft/2j ftP/ft. 190 4^
Disease or Cause ' >
of Death,! / Immediate,
Duration,
(p ft ^ Duration,
I certify that the above is true to the best of my knowledge and belief.
C/CKxic//
Signature and Residence '
of
Certifying Physician.
Date of Certificate,
inftf
ft
Uyi. 7
M. D.
ft].. i..h 190 ft
0
• Give also street and number, if any. \ 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
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COMMONWEALTH OF MASSACHUSETTS
FULL
{CITY OR TOWN.)
Registered No.
RETURN OF A DEATH
cuJf.. ^AjPialL. „ __ ....
PDeC,V- I ' °Z£\.@.ghk. '??. 190 y
Age i\^). years S.. month/ jc?.
Residence
days
STATISTICAL DETAILS
. VartArS Po
COLOR
Qi/u'jy
^DlVORCEXl’
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE*
NAME OF ) / . /7) C P ja-O y
father ( yy /%AAy J \J^r
BIRTHPLACE
OF FATHER*
QfriJbjfeuJ' WlayzO-
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER*
jP fj-irc cfy
OCCUPATION
INFORMANT §
<n
L
PLACE OF BURIAL OR REMOVAL II
UNDERTAKER
DATE OF BURIAL
(Da/'
( 1/I/7A/1/1 J?A
190 P/
ADDRESS
ryitJiAJ} /
PHYSICIAN’ S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from '(.... 190 ,^.to ..PPPfP^P... .y^f^T.190 .^f, f
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
‘
I
(duration) DAYS
Primary:
Contributory :
(Signed).
9SL Tl9 0 'Address
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted.
If not at place of death 7
Filed
.190.
Clerk
•City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or *
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
t State or country | also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
J.L
1 1 u »ii
b 1 * Z: % 1 f
O cc
£ '=
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
• Qyl /(l
r RETURN OF A DEATH
FULL NAME /A / Cst/OtC^
Wv
{Q'.£Ar~^ J A. .... .... (. Age b 3 years (&
Registered No.
Place of Death *
Date of Death
months .
^2.3,
days
STATISTICAL DETAILS
O t A
■+< hi 1 S\ V ,
COLOR
SWett, MARRIED,
WIDOWED, ©ft-
BLVOnOCB-
— L — f- *
MAIDEN NAMEt /1st Gjls
HUSBAND’S NAMEt ,/ _
BIRTHPLACE?
NAME OF
A
t '
p
BIRTHPL>&^
OF FATHER?
MAIDEN NAME
OF MOTHER
/
( ^ (r^Lst-
BIRTHPLACE
OF MOTHER?
FH Y SIC I AN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from . \q ../2Ue£..A$f£\90.l/,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary :
. (duration)..
Contributory :
OCCUPATION
fd..
. (duration)..
(Signed).
.^^.T./^.^?ri90.yf:.(Address)
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients
or Recent Residents.
Former or
How long at
Usual Residence Place of Death 7.
Days
INFORM
Where was disease contracted.
If not at place of death?.
Filed
.190. ...
Clerk
DATE OF BURIAL
ADDRESS
190 ^
* City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
J State or country; also city, town or county, If known,
§ Name and address of person giving statistical details.
II Name of cemetery.
-
• ,
1 10
NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
-I
<
4^ 31
STATISTICAL DETAILS
PHYSICIAN'S CERTIFICATE
SEX COLOR MNL.Lt, MARRIED,
1 HEREBY CERTIFY that 1 attended decease^ during last
illness, from.^ T| 190 ^ to 5 ./. 190 ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary: t /TUA'V't^ ’
MAIDEN NAME* ^lA^CXAsJ ^jb(TUP<L 71/1- CXSUZk.
HUSBAND’S NAMEt L' f , / /ryi
A^Za Lf& J^Tt //( Yj (yyuPi^
BIRTHPLACE* / (/
^
FATK" 4^ c^jeAyyU.a^k,
Contributory:
BIRTHPLACE . — .
0F Oma-M JVjQi
(Signed) V 1 i\aJ^( ^7 M.D.
MAIDEN NAME // r « /" 7/~
OF MOTHER ^ / r J) f
f ) {Tij£4-
^ ’\ i 190 (Address) ' .v* .7?^. ~ J
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or How long at
Usual Residence Place or Death 7 Days
Where was disease contracted.
If not at place of death?
BIRTHPLACE /i/ //
OF MOTHER* ^-r f ^
r 0vt//usu/ f/Lcu^
occupation ^-r-- ^
INFORMANT §
Filed
190 ...
Clerk
sj 7'fav JZ: 190
* City or town, street and number. If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow.
? State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
j^l|J)^pje of cemetery.
UNDERTAKER ( ^ ADDRESS
X§) uwmMsQphfjrMs of /yc^kf^ '/)
/ / f
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
(D&u tf*
r\
RETURN OF A DEATH
FULL NAME Registered No
vS **.
(Q.est^jh ..^.A^.. Age b 3 years... (p
Place of Death *
Date of Death
months .
<J>3,
days
STATISTICAL DETAILS
SEX
k¥vum>Jjl^ y&ihu
COLOR
smote, MARRIED,
WIDOWED, e«-
aivonoco
MAIDEN NAMEt /1st &JLA^£*~
HUSBAND’S NAME
BIRTHPLACE +
' , n
Ir-Lssl *7
XL
NAME OF
FATHER
BIRTHPL
¥
P PU
-i— » 1 —
OF FATHER*
MAIDEN NAME
OF MOTHER
$£4%.
r
BIRTHPLACE
OF MOTHER +
OCCUPATION
9
INFORMANT § f
PLACE OF BURIAL OR REMOVAL I
O'
DATE OF BURIAL
f
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from 190
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows
Primary:
c J*l?4trr1*s\Ur —
* City or town, street and number, If any, If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
J State or country; also city, town or county. If known.
§ Name and address of person giving statistical details.
|| Name of cemetery.
'
NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME... r Registered No^
Place of Death GteAtoL fklA..
Date of Death CO.^.^eZl u// /'/ Age d 5 /.
d'^3l
( o
.months .
days
STATISTICAL DETAILS
COLO
'Jfe
SINGLE, WAR-ffTEP,
vw?ow-&&T-cnr _ A , ' #
?2lawA!bcl
MAIDEN NAMEt CXAsj Al/L- OSlAL
HUSBAND’S NAMEt ^ O //
/C 'dlitripyL' >Tf /Ay) c/vuPtA^
BIRTHPLACE?
(gg
j 7 T/^
NAME OF , V
awjoAy
BIRTHPLACE
OF FATHER t
yv, O i
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER t
~~¥ 7 , /
Talcum
OCCUPATION
INFORMANT §
r
PLACE OF BURIAL ftft ftt
(JkMddh
UNDERTAKER I ‘
DATE OF BURIAL
190 7
, 4>
ADDRESS
U Vi'l/VIPA- ' &7^ Jr y, r/f
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended decease^ during last
illness, 190^. to 190 y,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary : UTU/f!^
o^di...^AA. ! ^
1..^,
Contributory :
<T?y\
. ( DU RAT ion). . . . .vrL/. .
(Signed)
fhu.
C V't 0\ajJ Uiix
I90A^. (Address) ’ .v1..
(DURATION) DAYS
M.D.
^
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or how long at
Usual Residence Place of Death?
How long at
Days
Where was disease contracted,
If not at place of death?
Filed
190.
Clerk
•City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information," If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
J State or country; also city, town or county. If known.
§ Name and address of person giving statistical details,
y j ^^IJfanje of cemetery.
NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH ' J
A , , W
FULL NAME... ■ Registered No
Place of Death * QjRX. Ci^UM mJ*.
Date Of Death CC). ^.v/. Age / years y? month*..... days
STATISTICAL DETAILS
PHYSICIAN’S CERTIFICATE
J2 . .
S Bt, COLOR SINGLE, MAR-ftteD^
DIVQRCEP'
1 HEREBY CERTIFY that 1 attended deceased during last
MMIDTN N A III C t
HU8BAMQIS NAME t
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
BIRTHPLACES
t
NAME OF /? /f-s
,ATB" fefoAAlc^fc.&hvjd
Contributory :
r [
BIRTHPLACE v
OF FATHER*/ \ / ' - /J „ -,
MAIDEN NAME / a
OF MOTHER CyVUX^
(Signed) „ M.D.
Jh^O I90..M (Address) J (
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or How long at
Usual Residence Place of Death? Days
Where was disease contracted,
If not at place of death?
BIRTHPLACE * V
OF MOTHER t > . ^ . .
/oW/i
occupation
informant}
Filed
190
Clerk
PLACE OF BURIAL On riCMOVAt- DATE OF BURIAL
(Wry ' | ^ „„ </
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information." If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
} State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
^j|/lame of cemetery. *
UNDERTAKER r ADDRESS
7 f
•r-
.
■
CITY OF BOSTON. COMMONWEALTH OF MASSACHUSETTS.
7;.
CITY OF
RETURN OF A DEATH-1904. BOSTON
FULL NAM E....MJ
Place of
and Residence
...X5....M.C.C.cU".&liy , Registered Nc
A,'. r - f
90 SI
(Vf, y
7eath l Boston Carney. Hospital ZY;...v... .. ...
idence )
Date of Death -.9..Y-.?. 1904. Age 7 year, 6..
-day*.
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
f eraale iM.t .e single
1 HEREBY CERTIFY that 1 attended deceased during last illness,
from 1904 to 1904,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary ) TvoilO 1 d F&Vpr
Birthplace W.ln tHr.Qp..i£as3 1...5
?.atZof J ohn J
(Duration) ( VCSJ
Q.ni.ia...3.. days
Birthplace T _ ,
of Father I.r.e.J.and
Contributory : |
(Duration) j
Maiden Name Annie McDade
Birthplace Ireland
of Mother F1. 9.
(Signed) w A Thompson M D
.?<>▼ 3 |904
SPECIAL INFORMATION from Ho«pital», ln«titutions, Tramiant*. or Recent
Resident!.
o"‘”mo.8.Tia' Holy Cross Malden .Kasa
Usual n-i.w. SO 3owdoin St -Alnthroji
Undertaker F S Haloney
Filed ,N0V 5 1904.
d —
Form C.
Cammontaltfr of IJlassarfeusette.
A
uVljtfy
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death, IS
Full Name of Deceased,
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
</
If a married or divorced
woman or a widow give also
/' " 190
6&aaj. AO
1 Maide
J Name of Husband,
Sex, 720. Color, Al/
Age, C y Years, -Months, .(T\ — Days. Occupation, QTz&Lt. /
" J /TO) A jO i 1 ' \A r
Married, Widowod or Divorood,
* Residence { afsoUsta°te fu%! } ...
Of
' Tl(dJr(2i/i6TtA. /& y.Tl./ .Jj/T/ t f// / 4 /o
Place of Death, UMRatvOtb S fileJ C/jr
Place of Birth, &/l4As%0 ^ _
Name and Birthplace of Father, 0. e n,dJ $~sCAaA AQ. {(.J/UAj
Maiden Name and Birthplace of MpUier, /l4JklTL/(^ (L/i AA J[ L'W, a Yl/h ' \
Place of Burial (Give name of Cemetery) ^
o
Signature and
place of business
'kTOTZ/rifd/..
t . / place of business ^ — i /I JpT j
- 190 V' of Undertaker. ^ /.O'' T ITAWA CVV O) tA&tJ
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased,!
Place and Date of Death,
d>:4r .<£) <7 Ill'll^- Age,, £>£y.CT±M.X^=&.
Disease or Cause j ^>r^marl >
of Death,? j Immediate,
/ 1 l
190 d
Duration, TO.~T..
..... Duration,
I certify that the above is true to the best of my knowledge and belief.
_M. D.
Signature and Residence \
of <
Certifying Physician, i
Date of Certificate, Jt IT) }
Dest ot my knowledge a
r>UL*0
wy.
• Give also street and number, if any. f Give sex of infant not named. If stubborn, so state,
t If a Soldier or Sailor in the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
RETURN OF THE DEATH
ALL NAMES TO BE IN FULL
/'/
COMMONWEALTH OF MASSACHUSETTS
„The text goes on. The rest is in the file.