USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1959 > Part 29
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[ R-302 1
× - PLACE OF DEATH
Middlesex (County) Lexington
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Lexington
(City or Town making this return)
Registered No.
((If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME ..
CHRISTINA J. LUNDGREN
(Was deceased a
Cannot
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ...
36 Cutler
(Usual place of abode)
Winthrop,
Massachusetts
(If nonresident, give city or town and State)
Length of stay: In place of death 20 years 0 months 10 days. In place of residence years.
.. months ..
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
10
1959
(Day)
(Month)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
April 1, 1958,
to May 10
59
I last saw @P ... alive onday ..... 10
195.9., death is said to
have occurred on the date stated above, at
1: 30 P ... m.
INTERVAL BETWEEN ONSET AND DEATH
?
Due To
(b)
Due To
(c)
OTHER
Heart failure
?
SIGNIFICANT
CONDITIONS
Was autopsy performed?
110
What test confirmed diagnosis?
clinical
5 Was disease or injury in any way related to occupation of deceased ?...... 10. If so, specify
(Signed)
Guiomar Silveira
M. D.
(Address) et Stato Hosp.
Date.May10,59
Holyhood Comctory Brookline 6 Place of Burial or Cremation (City or Town)
DATE OF BURIAL.
May 15
,59
7 NAME OF FUNERAL DIRECTOR. J. O Connor & Son ADDRESS 2 Tremont St. Roxbury
Received and filed
JUL 6 1959
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
emale
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED ZY
or DIVORCÉSLed
(write the word)
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
CharlesLundgren
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
AGE3
... Yez
ears
.Months.
Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry or Business :
15 Social Security No ..
Cannot learn
6 BIRTHPLACE (City) Boston. (State or country) Meggachusetts
17 NAME OF
FATHER
James M. White
18 BIRTHPLACE OF
FATHER (City).
Boston
(State or country) Massachusetts
19 MAIDEN NAME
OF MOTHER
Mary E. Ross
20 BIRTHPLACE OF
MOTHER (City)
Boston
(State or countryassachusetts
21 Informat Cords. Metropolitan Stato (Add )Sp. Waltham Sy, Mags.
A TRUE COPY James J. Carroll
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
May 13,
1959
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, (. 1 .. ) 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 .. .
PARENTS
25M-2-58-922072
No .. Metropolitan Stato Hospital
U. S. War Veteran,
if so specify WARLearn
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Bronchopneumonia
RECEIVED
MIN
6
.7
JUL -61959 /H
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
To be filed for burial permit with Board of Health or its Agent.
Registered No. 91
[(If death occurred in a hospital or institution, St. (give its NAME instead of street and number)
2 FULL NAME
Carla J. Adams
(If deceased is a married, widowed or divorced woman, give also maiden name.)
-
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No. 63 Walden St.
St.
(If nonresident, give city or town and State)
Length of stay: In place of death
3
years
months
days. In place of residence.
3
years
months.
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
June 2 1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
June 1958, 19.
to.
June 2nd
19.59
I last saw heralive on
June 1
19.29 , death is said to
have occurred on the date stated above, at
3.30 AMn.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Massive thrombocytopenia
bleeding
Due To
Acute lymphocytic leukemia
- (b) ....
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Bronchial pneumonia
Was autopsy performed?
No
What test confirmed diagnosis? Bone marrow biopsy
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
No?
(Signed).
(Address)
736 Cambridge Date
NOLiaÇI
Winthrop
M. D.
6/2 019
6
Winthrop
Place of Burial or Cremation
DATE OF BURIAL
(City or Town)
June 4, 1959
19
7 NAME OF
FUNERAL DIRECTOR
Arthur J . O'Maley
Winthrop Mass.
ADDRESS
JUN 3
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
White
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEDSingle
10a If married, widowed, or divorced
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
3
AGE
Years.
Months.
Days
If under 24 hours
Hours ...... Minutes
13 Usual
Occupation :
none
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
Winthrop
16 BIRTHPLACE (City)
(State or country)
Mass
|17 NAME OF
FATHER
Charles Adams
18 BIRTHPLACE OF
Revere
FATHER (City).
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Joyce Carter
20 BIRTHPLACE OF
Winthrop
MOTHER (City)
(State or country)
Mass
21
Informant (Address)
Charles Adams
63 Halden St Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was aled with me BEFORE the burial or transit permit-was issued :
(Signature of Agent of Board of Health or other)
6/3/59
(Official Designation)
(Date of Issue of Permit)
H
IR-301A
-THIS IS A IENT RECORD. e only APPROVED Ink or black iter ribbon.
RUCTIONS FOR CERTIFICATE
[ giving OF DEATH ot enter r than one for each (b) and (c)
L'oes not meon of dying, sheort foilure, etc. It meons ee. or compli- which coused
ns, if ony, ave rise to couse (0), the under- last. rause
sions contrib. oleoth but not the terminol ndition given
Chapter 137, 954, requires s to print or cause or t death on o tificates. FP. 46, 55 9 & HP. 114 $$ 45, CAP. 38 $ 6.)
2-58-923886
MARIO
Received and filed
No. 63 Walden St
PHYSICIAN - IMPORTANT -
(Usual place of abode)
INTERVAL
BETWEEN
ONSET AND
DEATH
2 days
1 year
PARENTS
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RECEIVED
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
12
2
19
6
RULES OF PRACTICE
The fulfillment of the purpose of these latt calls offs 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.
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
(Citfor Town making this return)
Registered No.
7.70
S(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME
Baby Boy McDonald
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ..
35 Plummer Avenue
S
intrano.
(If nonresident, give city or town and State)
Length of stay: In place of death ............ years. .months .. 2 days. In place of residence ........... years. months. ... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
June 5, 1959
(Month)
(Day)
(Year)
4 1 HEREBY CERTIFY,
That I attended deceased from
June 3, 1959,
to ...........
June 5
19.59
I last saw h .... malive on ...
June 5,
......
19.5.9, death is said to
have occurred on the date stated above, at
12:05p
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Tiyaline Membrane Diseaso
INTERVAL BETWEEN ONSET AND DEATH
Due To
Delivery
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed? What test confirmed diagnosis ?.
5 Was disease or injury in any way related to occupation of deceased? Jf so, specify
(Signed) Ralph A.Ross M. D.
(Address)
SI Brottle St. Date 6/5/
1950
inthrop Cem. Winthrop
6
Place of Burial or Cremation
June 9,
(City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Maurice w. Kirby
ADDRESS winthrop
Received and filed JUL-9-1959 19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
(write the word)
Male hite
10 SINGLE
MARRIED
WIDOWED
or DIVORCED no lo
10a If married, widowed, or divorced 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 ....
.Years.
Months 2
.. Days
If under 24 hours
.. Hours ........ Minutes
13 Usual
Occupation :..
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No ....
16 BIRTHPLACE (City)
Caro ridge
(State or country)
50
17 NAME OF
FATHER
Frank J. "cDonald
18 BIRTHPLACE OF
Boston
FATHER (City).
(State or country)
Mass .
19 MAIDEN NAME_
OF MOTHER
Louise Killian
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mass .
Salom
21 Informantar McDonald (Address) "> Lummer Ave. .. inthrop
A TRUE COPY Frederico 1.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
June 9,
19.
59
X
(h) 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) resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. 1 .. ) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
25M-2-58-922072
[ R-302 1
WKALL FLAINLI, WALD UNEAVIRU DLAVA ANA - THIS IS A FRAMANCHI ADLUKU
PARENTS
No. Mount Auburn Hospital
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(Usual place of abode)
RECEIVED
TONI
11 12
.1
JULE 31959 PM
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.
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
128 Terrace Ave.
St
(If nonresident, give city or town and State)
Length of stay: In place of death.
.. years
months
days. In place of residenceL.l
years_
months ...
. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
June (Month)
9th
1959 (Wear)
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEDMarried
4 I HEREBY CERTIFY, That I attended deceased from
, 19
to
19.
I last saw h.""alive on
., 19 ...
-, death is said to
have occurred on the date stated above, at
9:30 p.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Natural Causes
Presumably
(b)
Due To
Coronary Occlusion
sudden
Due To
Arteriosclerotic Heart Disease 10 yrs
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
no
What test confirmed diagnosis ?.
clinical
5 Was disease or injury in any way related to occupation of deceased? no If so, specify
M. D. (Ad Anthrop Board of Health
6 Winthrop
Place of Burial or Cremation
(CYty or Town)
21
Informant
Ralph O Andren
(Address) 128 Terrace Ave. Winthrop
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS Winthrop, Mass
Received and filed JUN 11 1959 19
(Registrar)
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
Flora MacMillan
20 BIRTHPLACE OF
MOTHER (City)
(State or country )
Nova Scotia
I HEREBY CERTIFY that a satisfactory standard certificate of death was fled with me BEFORE the burial or transit permit was issued: Ralph C. Jeranny. 8 (Signature of Agent of Board of Health or other)
6/11/59
(Official Designation) (Date of Issue of Permit)
X
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Ralph O Andren
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
Years
54
10
Months
7
Days
If under 24 hours
Hours ...... Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
Own Home
or Business:
None
15 Social Security No.
Westville
16 BIRTHPLACE (City)
(State or country)
Nova Scotia
17 NAME OFWilliam Ross FATHER
DATE OF BURIAL June 12
19.59
SOM-5-56-917573
RUCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one u for each (b) and (c)
does not mean . of dying, heart failure, ·tc. It means e. or compli- which caused
ns, if any, ave rise to cause (a), under- last.
-
the ause
aions contrib .- oleath but not the terminal ndition given
Chapter 137, 954, requires Ins to print or : cause or death on ctificates.
128 Terrace Ave. No.
f(If death occurred in a hospital or institution, St. [give its NAME instead of street and number)
Christine M (Ross) Andren
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence.
No.
(Usual place of abode)
11
(Day)
-
INTERVAL
BETWEEN
ONSET AND
DEATH
PERSONAL AND STATISTICAL PARTICULARS
Registered No.
Date 10 June 1959. Winthrop
MIR-301A 1
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 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 of 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.
N6. undettaker 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 of thelfuneral 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.
11. 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 : Attending physicians will certify to such deaths only as those of persons to runm they have given bedside care during a last illness from disease unrelated Any form of injury.
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 These include not only deaths caused directly or indirectly by JURnatangh Quting 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.
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) Winthrop (City or Town)
office copy 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.
190 Pleasant St No.
Jacob Glazier
(If deceased is a married, widowed or divorced woman, give also maiden name.)
2 Lawrence
St.
Chelsea
(If nonresident, give city or town and State)
Length of stay: In place of death ... years months .. 1 days. In place of residence
63
years
months.
_...... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
June
10
1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
2/1.9
to 12:1
1957
I last saw hispalive on
2/11
192, death is said to
have occurred on the date stated above, at
2 P.,
.m.
INTERVAL BETWEEN ONSET AND DEATH
1/2 /2
12
AGE 63 Years.
Months
Days
If under 24 hours
-.
Hours ....... Minutes
13 Usual
Occupation :
Contractor
(Kind of work done during most of working life)
14 Industry
or Business :
Building
15 Social Security No.
013 28
6/09
16 BIRTHPLACE (City)
(State or country)
Russia
17 NAME OF
FATHER
Kalman Glazier
18 BIRTHPLACE OF
FATHER (City) (State or country)
Russia
19 MAIDEN NAME
OF MOTHER
C. B.L.
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
21 Dr. William Glazier
(Address)
190 Pleasant Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Table C. ferias
1
seattle Merecer
(Signature of Agent of Board of Health or other)
6/11/59
(Official Designation)
(Date of Issue of Permit)
X
8 SEX
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Anna Gordon
Married
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
DE2 KGMARY
(a)
THROMBOSIS
Due To
CORONARY HEART
(b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
ILFATTO
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
, M. D.
(Address)
(Signed)
221 Husket Date is )
19.63
TEMPLE ISRAEL Cem, Peabody
.
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL June 11
7 NAME OF
FUNERAL DIRECTOR
Torf Funeral Servicio
ADDRESS 151 Washington St Chelsea
Received and filed JUN 11 1959 19
(Registrar)
PARENTS
Registered No.
f(If death occurred in a hospital or institution,
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