USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1959 > Part 2
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Medical examiners shall make examination unos the wiet of the dead bodies of persons as are supposed to have died by violence, or by the action of chemical, thermal or electrical agents or following abortion, or from diseases resulting from injury or infection relating to occupation, or suddenly when not disabled by recognizable disease, or when any person is found dead. .. - General Laws, Chap, 38, Sec. 6., as amended by Chap. 632, Seg. 4, Acts of 1945.
No undertaker or other persons shall bury a hurdan body or the ashes thereof which have been brought into the commonwealth until he bas 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 derk 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 6
The fulfillment of the purpose of these laws call 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 , ut illness trong 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 a (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 deaths of persons not disabled by recognized disease, and those of persons found dead.
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
x PLACE OF DEATH
Suffolk (County)
1
Winthrop (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
Registered No.
J(If death occurred in a hospital or institution,
St. [give its NAME instead of street and number) -
PHYSICIAN - IMPORTANT
2 FULL NAME 118-41100- PHYSTER Edwards
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 94 Somerset Avenue
(If nonresident, give city or town and State)
Length of stay: In place of death years 7 months 27 days. In place of residence 30 years.
.months ..
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
January 8, 1959
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
JULY
1954, to.
JAN
8
1959
I last saw h __._ alive on
JAN 6
1959, death is said to
have occurred on the date stated above, at
12:30 P
.m.
INTERVAL
BETWEEN
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
ONSET AND
, DEATH
2 days.
Due
ARTERIOSCLEROTIC HEART DISEASE
- (b)
10 yes
Due To
ARTERIOSCLEROSIS
10 yres
OTHER
SIGNIFICANT CIREBRAL HEMORRHAGE
CONDITIONS
Nov. 26
1458
Was autopsy performed?
No
What test confirmed diagnosis ?.
5 Was disease or injury in any way related to occupation of deceased? No If so, specify.
(Signed).
Dorothy Cheney appleton
M. D.
197 Woodside Che
Date Jan. 9
. 1959
6
Place of Burial or Cremation (City or Town)
DATE OF BURIAL .._.
January/10 1959
7 NAME OF
FUNERAL DIRECTOR ....
ADDRESS
174 Winthrop St. Winthrop,
Received and filed 1 January 9, 19:59
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED Garried
or DIVORCED
female
white
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Charles Edwards
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE57
.Years.
2
Months
30Days
If under 24 hours
Hours .....
Minutes
13 Usual
Occupation: retired regestered nurse
(Kind of work done during most of working life)
14 Industry
general and hospital nursim
15 Social Security No .......... n.o.n.e.
16 BIRTHPLACE (City)
(State or country)
Canada
17 NAME OF
FATHER
Henry Physter
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
Hannah
3
20 BIRTHPLACE OF
MOTHER (City)
unknown
21
Informant Mrs Sarah Whorf
(Address)
94 Somerset Ive Winthrop
LAI HEREBY CERTIFY that A satisfactory standard certificate of death was filed with me BEFORE the brial or transit permit was issued :
Mass. Graphic. Jerianne f. (Signature of Agent of Board of Health or other) Healthol Mueck 1/9 59
(Official Designation) (Date of Issue of Permit)
e
In giving E OF DEATH o not enter re than one use for each ), (b) and (c)
is does not mean node of dying, as heart failure, a, etc. It means sease, or compli- which caused
itions, if any, h gave rise to cause (a), ng the under- cause last.
unditions contrib- to death but not to the terminal : condition given .
:- Chapter 137, of 1954, requires cians to print or the cause or s of death on certificates. CHAP. 46, 55 9 & CHAP. 114 $$ 45, CHAP. 38$6.)
M.S.
OM. 10.58-923886
MR-301A
B .- THIS IS A ANENT RECORD. Use only TE APPROVED k ink or black writer ribbon.
STRUCTIONS FOR CAL CERTIFICATE
(Usual place of abode)
St.
(Was deceased a
U. S. War Veteran,
if so specify WAR)
NO.
To be filed for burial permit with Board of Health or its Agent.
No ..
Bay View Nursing Home
PARENTS
unknown
Winthrop Cemetery Winthrop, Mass 02 (State or country)
(c)
(a)
ACUTE MYOCARDIAL INSUFFICIENCY
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RECEIVED
TO!
OF
11 12 1
CLERK
6
JAN -91959 AM
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 deaths of persons not disabled by recognized disease, and those of persons found dead.
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.
PLACE OF DEATH
Suffolk (County) Winthrop (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 Agent.
5
Registered No.
S (If death occurred in a hospital or institution,,
St. { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
No
(If deceased is a married, widowed or divorced woman, give also maiden name.)
83 Somerset Ave. St
Length of stay: In place of death ..... .. years. $5 months days. In place of residence.
1
.years.
5
... months ........
... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
14
(Day)
1959
(Year)
4 I HEREBY CERTIFY,
11/18
57
to
1/14
That I attended deceased from
1959
I last saw himalive on
1/13
1959 de
have occurred on the date stated above, at
Si A
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
BRONCHO-PNEUMONIA
(a)
Due To (b)
Due To APTERIO-SCLEROTIC
(c)
HEART DISEASE
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? AG If so, specify.
(Signed)
(Address) 13 Pleasingis eenthor /14
1955
(City or Town) Cambridge Catholic Cem Cambridge Place of Burial or Cremation
DATE OF BURIAL January 17 1959
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Naley
ADDRESS
Winthrop
Mags
JAN 16 1959
19
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEDVidowed
10a If married, widowed, or
divorced
Mary
Heaney
HUSBAND of.
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 75 Years.
Months ...
.Days®
13 Usual
Retired Gardener
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
Land.g.cape
15 Social Security No ...
16 BIRTHPLACE (City)
(State or country)
Ireland
17 NAME OF
FATHER Jeremiah Mahoney
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
Julia Hurley
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
21 Eugene Mahoney
Informant
(Address)
83 Somerset Ave., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed With me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other) Sealleto Officer 11/6/49
(Official Designation)
(Date of Issue of Pernyt)
X
RUCTIONS FOR L CERTIFICATE
giving OF DEATH not enter than one e for each (b) and (c)
· does not mean de of dying, heart failure, , etc. It means ase, or compli- which caused
tions, if any, - gave rise to causc (a), g the under- cause last.
ditions contrib- o death but not to the terminal condition given
e :- Chapter 137, of 1954, requIres cians to print or the cause or s of death on certificates.
100M-11-55-916145
1 R-301A 1
No.
83 Somerset Ave.
Michael Mahoney
2 FULL NAME
(a) Residence. No. (Usual place of abode)
(If nonresident, give city or town and State)
Treland
M. D.
PARENTS
INTERVAL BETWEEN ONSET AND DEATH 2 DAYS
If under 24 hours
Hours ........ Minutes
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- te 'n, shall. if the deceased, to the best of his knowledge and belief, served in the army, 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 shall exhume 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 persons as are supposed to have died by violence, or by the action of chemical, thermal or electrical agents or following abortion, or from diseases resulting from injury or infection relating to occupation, or suddenly when not disabled by recognizable disease, or when any person is found dead. .. - General Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.
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
1
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, for electrical agents. and deaths following abortion, but also deaths from disease Resulting from injury or infection related to occupation, the sudden deaths of persons not' disabled by recognized disease, and those of persons found dead.
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
X
PLACE OF DEATH
Middlesex (County) Cambridge
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Cambridge (City of Town making this return)
Registered No.
80
6
§(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
No.
Many Shaw
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WARTO
590 Shirley Court
sfinthron, Massachusetts
(If nonresident, give city or town and State)
(a) Residence. No ....
(Usual place of abode)
months.
9
.days. In place of residence.
.. years ..
months ............ days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
January 18, 1959
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
January 9,19 59
50
to ....
January 18,
I last saw h ....... alive on
January 10. 19.2.9, death is said to
have occurred on the date stated above, at
7:45p.m.
INTERVAL BETWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
12 78
1
Days
If under 24 hours
Hours ........ Minutes
13 Usual
Housewife
Occupation :
(Kind of work done during most of working life)
14 Industry
At Home
or Business :.
15 Social Security No .....
None
16 BIRTHPLACE (City Noston (State or country)
17 NAME OF
FATHER
Joseph Chadbourne
18 BIRTHPLACE OF
FATHER (City) DOston, Mass .
(State or country)
19 MAIDEN NAME
OF MOTHER
Catherine Kenney
20 BIRTHPLACE OF
Ireland
MOTHER (City).
(State or country)
21 Mrs. James Roche-cousin
Informant .. ,
(Address) 07 DIX Rd ....
sterfield, Conn.
7 NAME OF
Charles P. Chapman
FUNERAL DIRECTOR. 490 Columbia Rd. Dorchester
ADDRESS
Received and filed .. TEb 41959 19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
hito
MARRIED
WIDOWED. ..
or DIVORCED. dowed
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
John J. Shaw
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Metastatic carcinoma to
Due To abdomen, lung and bone (1)) (primary site undetermined)
OTHER
SIGNIFICANT
CONDITIONS
no
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
Philip J, Landry Jr.
M. D.
(Address).
Holy Ghost Hosp ... Jan. 19 19 59
New Calvary em. Boston
6
Place of Burial or Cremation
Jan. 22,
,59
19
(City or Town)
DATE OF BURIAL
A TRUE COPY
2>
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED Jan. 19, 19 59
V.G. . .
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. I .. ) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town Due To (c)
M R-302 1
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
PARENTS
25M-2-58-922072
Holy Ghost Hospital
Stree
Length of stay: In place of death .......... years ....
10 SINGLE
(write the word)
AGE.
Years ..
25
RECEIVED
TO
11.12
10
6
FEB : 41959 AM
X
PLACE OF DEATH
Suffolk (County)
Winthrop (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 Agent.
Registered No.
f(If death occurred in a hospital or institution, St. [give its NAME instead of street and number)
2 FULL NAME
Idore Bror Tornrose
(If deceased is a married, widowed or divorced woman, give also maiden name.)
64 Bates Avenue
St.
(If nonresident, give city or town and State)
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death.55years.
months.
days. In place of residence ....
55years ......__ months.
.... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January
22
1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
1/20
1959
That I attended deceased from
1959
to
1/22
I last saw h/ kalive on
1/20
1959, death is said to
have occurred on the date stated above, at
8 3 Am."
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
GANGRENE - LEFT FOOT FLEG
(a)
INTERVAL
BETWEEN
ONSET AND
DEATH
3 mo
11 IF STILLBORN, enter that fact here.
12
AGE 86 Years ..... 5 Months.
Q Days
If under 24 hours
„Hours ....._ Minutes
13 Usual
Occupationretired manufacturer
(Kind of work done during most of working life)
14 Industry
Business
ornamental light fixtures
15 Social Security No ......
033-16-1304
Lilla Edith
16 BIRTHPLACE (City)
(State or country)
Sweden
17 NAME OF
FATHER
Jan Peter Tornrose
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Sweden
19 MAIDEN NAME
OF MOTHER
Ina Lena Engelbreekt
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Sweden
21
Informant
oliver.W.Tornrose
(Address) 337 washington St. Felrose I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was I'ssued : Talle C. Jircannes
Mass
(Signature of Agent of Board of Health or other)
health Officer
1/23/59
(Official Designation)
(Date of Issue of Permit)
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