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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