Town of Winthrop : Record of Deaths 1954, Part 26

Author: Winthrop (Mass.)
Publication date: 1954
Publisher:
Number of Pages: 566


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1954 > Part 26


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Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.


Statement of Occupation .- Precise statement of occupation is very import- ant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Children not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, eook-hotel, etc. For a person who had no occupation whatever write none.


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE. DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER.


COPY OF CERTIFICATE OF DEATH


CERTIFICATE OF DEATH STATE OF NEW HAMPSHIRE


TOWN OR CITY CLERK'S NO


1. NAME OF


a. (First)


DECEASED


(Type or Print)


Leonora


b. (Middle)


Lewis


c. (Last)


Smith


2. DATE


OF


DEATH


(Month)


(Day)


(Year)


March


29


1954


3. PLACE OF DEATH


a. COUNTY


Merrimack


4. USUAL RESIDENCE (Where deceased lived. If institution: resid-


a. STATE


b. COUNTY


Rockingham


New Hampshire


ence before admission).


b. CITY


OR


TOWN


Concord


c. LENGTH OF


STAY (in this place)


4yrs .20 day's-TOWN


c. CITY (Give actual town of residence, NOT mailing address).


OR


Rye


d. FULL NAME OF (If not in hospital or institution, give street address or location)


HOSPITAL OR


INSTITUTION


N.H. State Hospital


d. STREET


ADDRESS


(If rural, give location)


5. SEX


Female


6. COLOR OR RACE


White


17. MARRIED, NEVER MARRIED.


WIDOWED, DIVORCED (Specify)


Married


18. DATE OF BIRTH


Nov. 27, 1873


9. AGE (In years


last birthday)


80


IF UNDER 1 YEAR Months! Days


Min. IF UNDER 24 HRS- Hours


10a. USUAL OCCUPATION (Kind of work done during most of working life, even if retired) Housewife


10b. KIND OF BUSINESS OR IN-


DUSTRY


11. BIRTHPLACE (State or foreign country)


Cambridge, Mass.


12. CITIZEN OF WHAT


COUNTRY?


13. FATHER'S NAME


John L. Lewis


14. MOTHER'S MAIDEN NAME


Frances L. Lewis


1S. WAS DECEASED EVER IN U. S. ARMED FORCES?


(Yes, no, or unknown) | (If yes, give war or dates of service)


no


16. SOCIAL SECURITY 17. INFORMANT


NO.


Record of N.H. State Hospital


MEDICAL CERTIFICATION


INTERVAL BETWEEN ONSET AND DEATH


II. OTHER SIGNIFICANT CONDITIONS


Conditions contributing to the death but not


related to the disease or condition causing it.


19a. DATE OF OPERA- 19b. MAJOR FINDINGS OF OPERATION


TION


20. AUTOPSY?


YES


NO


21a. ACCIDENT


SUICIDE


HOMICIDE


(Specify)


21b. PLACE OF INJURY (e.g., in or about


home, farm, factory, street, office bldg., etc.)


21d. TIME


OF


INJURY


(Month) (Day) (Year) (Hour)


m.


21e. INJURY OCCURRED


WHILE AT


WORK


AT WORK


NOT WHILE


21f. HOW DID INJURY OCCUR?


X


22. I hereby certify that I attended the deceased from ... ar. .... 28 , 1954., to.Mar .. ... 29 , 1954., that Ilast saw the deceased alive on Mar. 29, 19 . .... 5Land that death occurred at


23a. SIGNATURE


S. George Brown


( Degree or title)


M. D.


23b. ADDRESS


N.f. State Hospital


23c. DATE SIGNED


3-29-54


24a. BURIAL. CREMATION, 24b. DATE


ENTOMBMENT, REMOVAL


Burial


( Specify)


3-31-54


24c. NAME OF CEMETERY OR CREMATORY |24d. LOCATION (City, town, or county ) (State)


Winthrop,


lass.


Winthrop Cemetery


IF ENTOMBED


24e. PLACE OF BURIAL


( Name of Cemetery)


LOCATION (City, Town, County)


(State)


DATE


25. FUNERAL DIRECTOR


George B. Ward


ADDRESS


Portsmouth, NH


COUNTERSIGNED - AGENT (City Bd. of Health)


Pierre A. Boucher, M. D.


DATE


4-2-54


DATE REC'D BY TOWN OR CITY CLERK


April 2, 1954


CLERK'S OWN SIGNATURE


Arthur E. Roby


CLERK OF


Concord, N. H.


A true copy, Attest:


Clerk of ..... Concord, N. H.


Dated Apr. 2 1954


V. S. 17


1-53-50M


18. I. DISEASE OR CONDITION DIRECTLY LEADING TO DEATH This does not mean the mode of dying, such as heart failure, asthenia, etc. It means the disease, injury, or complication which caused death.


(a) ..


Arteriosclerotic heart disease


DUE TO


(b)


Generalized arteriosclerosis


ANTECEDENT CAUSES


Morbid con-


ditions, if any, giving rise to the above cause


(a) stating the underlying cause last.


(c)


DUE TO


21c. (CITY OR TOWN)


(COUNTY)


(STATE)


6:45 Am., from the causes and on the date stated above.


APR-5


R-301A 1


PLACE OF DEATH Suffolk (Coupty)-


(City of Town"


The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


To be filed for burial permit with Board of Health or its Agent.


78


Nultuo Com Thack No.


J(If death occurred in a hospital or institution. . St. [ give its NAME instead of street and number)


PHYSICIAN - IMPORTANT


Į (Was deceased a U. S. War Veteran. if so specify WAR)


27 Triton Que


St.


(If nonresident, give city or town and State)


Length of stay: In place of death years. months.


1 days. In place of residence


40 years. .months days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Female N Lite


10 SINGLE


MARRIED


WIDOWED


or DIVORCED


(write the word)


Marcel


4 I HEREBY CERTIFY,


That I attended deceased from March28 1954 to. march 30. 1954


I last saw her alive on. march 30, 1954, death is said to


have occurred on the date stated above, at 12:15 A. m.


INTERVAL BE- TWEEN ONSET ANO DEATH 36 hrs


11 IF STILLBORN, enter that fact here.


12


AGE


4.3 Years


Months


Days


If under 24 hours


Hours


.Minutes


13 Usual


Occupation :


Ttome


(Kind of work done during most of working life)


14 Industry or Business:


15 Social Security No.


16 BIRTHPLACE (City) (State or country)


My City M M


17 NAME OF FATHER


Michael Dineen


18 BIRTHPLACE OF FATHER (City) (State or country)


reland


19 MAIDEN NAME OF MOTHER


Mina Mc Mail


20 BIRTHPLACE OF MOTHER (City) (State or country)


wieland


21 Informant (Address)


Charles It Director


I HEREBY CERTIFY that a satisfactory standard/certificate of death was filed with me BEFORE the burial of transit permit was issued: Halter A. Lakers g. (Signature of Agent of Board of Health or other)


ADDRESS


Received and filed.


APR 11554-


19


(Registrar)


36 lira


ANTE


CEDENT (b)


CAUSES


Occlusion


Coronary


,


(c)


Enterosclerotic


heart disease


OTHER


SIGNIFICANT


CONDITIONS


Major findings:


Of operations.


Was autopsy performed ?.


no


What test confirmed diagnosis?


Electrocardiogram


5 Was diseas


If so, specty chy mo de leased?


(Signedy ...


(Address) )Vanthrop


M. D.


Date 3.1 March 1954.


(City or Town)


Place of Burial or Cremation DATE OF BURIAL Abril 2 195$


7 NAME OF


FUNERAL DIRECTOR


100M-(D)-10-48-24858


UCTIONS FOR CERTIFICATE


iving OF DEATH t enter han one for each b) and (c)


oes not mean f dying, such ure, asthenia, ns the disease, ations which h.


I conditions, ng rise to the : (a) stating ying cause


ions contrib- death but not e disease or using death.


11 5.


March 3.0 1954 (Year)


(Month)


(Day)


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full) Charles 26


(or) WIFE of


(Husband's name in full)


DISEASE OR CONDITION


DIRECTLY LEADING


TO DEATH


Myocardial


Infarction


3 DATE OF


DEATH


9 COLOR OR RACE


Registered No.


WINIFRED K(DINEEN) WHEATON (If deceased is a married, widowed 'or divorced woman, give also maiden name.)


2 FULL NAME.


(a) Residence. No. (Usual place of abode)


(Official Designation)


(Date of Issue of Permit)


PARENTS


Date of operation


-


EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE


RETURN OF CERTIFICATES OF DEATH


A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . . Gen. Laws, Chap. 46, Sec. 9.


A physician or officer furnishing a certificate of death as required by the preceding section or by section forty-five of chapter one hundred and four- teen, shall, if the deceased, to the best of his knowledge and belief, served in the arrny, navy or marine corps of the United States in any war in which it has been engaged, insert in the certificate a recital to that effect, specifying the war, and shall also certify in such certificate both the primary and the secondary or imme- diate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer, shall forfeit ten dollars. For the purposes of this section and of sections forty-five, forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relief expedition and the Philippine insurrection, which Shall. for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of nineteen hundred and sixteen and nineteen hundred and seventeen. G. L. Chap. 46, Sec. 10.


No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health, or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shallexhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board, agent or clerk, as the case may be. a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original inter- ment, by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot be obtained early enough for the purpose. the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the


death certificate contains a recital, as required by section ten of chapter forty-six. that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersign it and transmit it to the clerk of the town for registra- tion. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chap. 114, Sec. 45, G. L., (Tercentenary Edition).


Medical examiners shall make examination upon the view of the dead bodies of only such' persons as are supposed to have died by violence. If a medical examiner has notice that there is within his county the body of such a person, he shall forthwith go to the place where the body lies and take charge of the same; . . General Laws, Chap. 38, Sec.6. .


No undertaker or other persons shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the body is to be buried or the funeral is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made.


. . . Chap. 114, Sec.46, G. L., (Tercentenary Edition).


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the follow- ing rules of practice:


(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.


(2) Board of Health physicians will certify to such deaths only as those of persons who) though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.


(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden death's of persons not disabled by recognized disease, and those of persons found dead. 1


Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.


Statement of Occupation .- Precise statement of occupation is very import- ant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Children not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER


M R-302 1


3 DATE OF


DEATH


WRITE PAINET, WETT ONPAVING DLAGR INA - THIS IS APERMANENT RECORD


ANTE


CEDENT (b)


CAUSES


March


9


1954


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY,


That I attended deceased from


February 19 19 54


to


March.9.


19


54


I last saw h.


im alive on


March 9


19.54 death is said to


have occurred on the date stated above, at


7:36 ao ... m.


INTERVAL BE- TWEEN ONSET AND DEATH


DISEASE OR CONDITION


DIRECTLY LEADING


TO DEATH (a)


Cerebral Thrombosis


Due To


General Arteriosclerosis


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


Hemiparesis - right


Major findings: Of operations.


Date of operation


no


.Was autopsy performed?


no


What test confirmed diagnosis ?.


.. clinical


5 Was disease or injury in any way related to occupation of deceased? If so, specify Irving H Park M. D.


(Signed).


1751, Beacon St


Date March 10, 51


(Address)


Brookline Mass


6 Pride of Boston Montvale,Massachusetts Place of Burial or Cremation


DATE OF BURIAL


March .... 10


19.54


7 NAME OF


FUNERAL DIRECTOR.


Benjamin F Solomon


ADDRESS


420 Harvard St. Brookline, Mass.


Received and filed.


April 121954


19


(Registrar of City or Town where deceased resided)


PARENTS


18 BIRTHPLACE OF


FATHER (City).


(State or country)


Poland


19 MAIDEN NAME


OF MOTHER


Bertha (cannot be learned)


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Russia


21 Rose Marden


Informant


(Address)


40 Browne St., Brookline, Mass.


A TRUE COPY


ATTEST:


(Registrar of City or Town where death occurred)


DATE FILED


March 11


19 54


25M (E)-6-50.902253


PLACE OF DEATH


(County) BROOKLINE


(City or Town)


The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


BROOKLINE


(City or town making return)


79


Registered No.


213


[(If death occurred in a hospital or institution,


St. \ give its NAME instead of street and number)


2 FULL NAME


Frank Ruskin


(If deceased is a married, widowed or divorced woman, give also maiden name.)


53 Trident Avenue


St.


Winthrop, Massachusetts


(If nonresident, give city or town and State)


Length of stay: In place of death. ....... ... years ... months. days. In place of residence. ........... years. .months .days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


male


9 COLOR OR RACE


white


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCED


widowed


10a If married, widowed, or divorced


Minnie Bosick


HUSBAND of.


(Give maiden name of wife in full)


(or) WIFE o


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


3 months 12


AGE. 85 ... Years.


Months


.Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


Tailor (retired)


(Kind of work done during most of working life)


14 Industry or Business:


15 Social Security No ...


none


16 BIRTHPLACE (City)


(State or country)


Poland


17 NAME OF


FATHER


Charles Ruskin


Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time after the close of the month in which the death occurred. (See Chap. 46, Ser 12. G. L.) of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible


I.S.


NORFOLK


No.


Beth El Nursing Home - 24 Winthrop Road


(Was deceased a


U. S. War Veteran,


if so specify WAR)


(a) Residence. No. (Usual place of abode)


APR1 ;;


X


-


Suffolk


(County)


Chalsoa (City or Town)


The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF


CERTIFICATE OF DEATH


Chelsea (City or town making return)


Registered No.


145


80


No. Soldiong' "one Hos ital


J(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)


2 FULL NAME


Geor e Towle Day


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No.


70 Moura


(Usual place of abode)


St.


Winthrop


(If nonresident, give city or town and State)


Length of stay: In place of death ......... years ..


1


months .. 2.6 .. days. In place of residence


.years. ...


... months ...... ... days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


(Month)


4 I HEREBY CERTIFY,


Oct.20


,53


CEDENT (b)


Due To


(c)


OTHER


SIGNIFICANT


CONDITIONS


Major findings:


Of operations.


Date of operation.


6


Place of Burial or Cremation


Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time


50m-(e)-10-48-24658


after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)


of death should be transmitted on Form R-302 to the clerk of the city or town in which the deccased resided as soon as possible


CAUSES


metastases


Ler.16.7954


(Day)


(Year)


That I


attended deceased from


to ..


Ihr.16


19


54


I last saw h ... ][.] .. alive on


hr.16.


19 .D4death is said to


have occurred on the date stated above, at


m.


INTERVAL BE- TWEEN ONSET AND DEATH


11 IF STILLBORN, enter that fact here.


12


67


6


AGE


Years


Months


1


Days


If under 24 hours


Hours ...


Minutes


13 Usual


appr. 3jrs occupation:


Millman


(Kind of work done during most of working life)


14 Industry or Business:


15 Social Security 1027-07-7826


16 BIRTHPLACE (City).


(State or country)


Angerville, Lass,


17 NAME OF


FATHER


Trod M.


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Maine


19 MAIDEN NAME OF MOTHERosop ino Heulin


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


New York


21 Harital Records


Informant.


(Address)


A TRUE COPY esple aTyrrell


ATTEST:


(Registrar of City or Town where death occurred)


DATE FILED


Mar.17,1954


19


X


(Registrar of City or Town where deceased resided)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR OR RACE


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCED4 -oneed


10a If married, widowed, or divorced


HUSBAND of.


Thorosa .Shea


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a) cidermoid carcinoma of


ANTE


Due To


larynx with


Was autopsy performed ?..


.. no


What test confirmed diagnosis ?.


biopsy


5 Was disease or injury in any way related to occupation of deceased? If so, specify,.


(Signed)


Volle are Jansons


M. D.


(Address) Cholcon Vinga Date 7x1 1954


..... (City of Town)


DATE OF BURIAL


Ihr.10.1954


19


7 NAME OF


FUNERAL


Join C Kelly


ADDRESS


Ct. I. Backon


Received and filed


$1 20


19


1954


4. 5.


PLACE OF DEATH


M R-302 1


WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD


PARENTS


(Was deceased a


WVI


U. S. War Veteran.


{ if so specify WAR)


APR20


Enlisted Aug. 5,1917 Discharged Aug.29,1919 Captain Motor Supply Train o124623


R-301A 1


PLACE OF DEATH


Suffuels (County) Wwhtheage (City or Town)


The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


To be filed for burial permit with Board of Health or its Agont.


81


46 Pearl Ave. Winthrop No.


[(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)


Harris H. enastos


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No. 46 Pearl Ave


Winthank


(If nonresident, give city or town and State)


Length of stay: In place of death. 34 .years months.


days. In place of residence 34 years. months .days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


male


9 COLOR OR RACE


white


10 SINGLE


(write the word)


MARRIED


WIDOWED /


or DIVORCED I towed


4 I HEREBY CERTIFY,


3/18


to


Capa 1


19


I last saw h unalive on


3/50


19:57, death is said to


have occurred on the date stated above, at


13º17 m.


INTERVAL BE- TWEEN ONSET AND DEATH


11 IF STILLBORN, enter that fact here.


12


AGE/9 Years


Months.


.Days


If under 24 hours


Hours ... ... Minutes


13 Usual


Occupation:


I Det


(Kind of work done during most of working life)


14 Industry


or Business:


Dealer


15 Social Security No.


NONE


16 BIRTHPLACE (City) PREECE (State or country)


17 NAME OF


FATHER


Christos ANASTOS


PARENTS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


GREECE


19 MAIDEN NAME


OF MOTHER


Unknown


20 BIRTHPLACE OF MOTHER (City) (State or country)


21 Informant Theodore Ci Anastos


(Address) La Pearl Ave Wintherk death, was


I HEREBY CERTIFY that a satisfactory standard certificate of de filed with me BEFORE the burial or transit petnuit was issued! struttura Walter f. Kr aller (Signature of Agenf of Board of Health or other)


Health Oficer 4.2.54


(Official Designation) (Date of Issue of Permit)


SOM-3-53-909098


6


Winthrop Cemetery Winthroplake


Place of Burial or Cremation (City or Town)


DATE OF BURIAL


upRil 3.


1954


7 NAME OF


FUNERAL DIRECTOR


Arthur C. Hasits


ADDRESS. 647 Cm


Received and filed. APR 2 luv. 19


(Registrar)


1 gr


Due To (c)


OTHER


SIGNIFICANT camil hernien


CONDITIONS


Major findings:


Of operations.


Date of operation


.. Was autopsy performed?


What test confirmed diagnosis?


Cimail


.


5 Was disease or injury in any way related to occupation of deceased ?. /Le If so, specify. - (Signed) (Address):>22 Pleasant ST in with Date 4/1 1954


M. D.


1


1954


(Year)


(Month)


(Day)


That I attended deceased from


10a If married, widowed, or divorced


HUSBAND of STAVBOULA


(Give maiden name of wife in full)


VARELAS


(or) WIFE of


(Husband's name in full)


DISEASE OR CONDITION


DIRECTLY LEADING


TO DEATH (a) Cicale Contrary


ANTE


· Artimi velivotre Heart Dis


CEDENT (b)


...


CAUSES


with unglative for love


15 ys


UCTIONS OR CERTIFICATE


iving OF DEATH t enter han one for each b) and (c)


oes not mean f dying, such ure, asthenia, is the disease. ations which h.


conditions. ng rise to the (a) staling ying cause


ons contrib- death but not e disease or using death.


M.s.


Registered No.


2 FULL NAME.


PHYSICIAN - IMPORTANT


(Was deceased a


U. S. War Veteran,


if so specify WAR)


200


(Usual place of abode)


3 DATE OF


DEATH


EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE


RETURN OF CERTIFICATES OF DEATH


A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased. furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died. defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . . Gen. Laws, Chap. 46, Sec. 9.




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