CERTIFICATION OF VITAL RECORD

City of Waco, Texas

TEXAS DEPARTMENT OF HEALTH

BUREAU OF VITAL STATISTICS

STATE OF TEXAS

CERTIFICATE OF DEATH

STATE FILE NO.

1. PLACE OF DEATH

a. COUNTY: McLennan
b. CITY OR TOWN (If outside corporate limits write RURAL and give precinct no.): Waco
c. LENGTH OF STAY (in this place): 20 yrs.
d. FULL NAME OF HOSPITAL OR INSTITUTION (if not in hospital or institution, give street address or location): Hillcrest Hospital

2. USUAL RESIDENCE (where deceased lived. If institution: residence before admission)

a. STATE: Texas
b. COUNTY: McLennan
c. CITY OR TOWN: (If outside corporate limits, write RURAL and give precinct no.): Mt. Carmel Center
d. STREET ADDRESS: (If rural, give location): Waco, Route 1.

3. NAME OF DECEASED: (Type or Print)

a. (First): Victor
b. (Middle): T.
c. (Last): Houteff

4. DATE OF DEATH: Feb. 5, 1955
5. SEX: Male
6. COLOR OR RACE: White
7. MARRIED, NEVER MARRIED, WIDOWED, DIVORCED (Specify): Married
8. DATE OF BIRTH: Mar 2, 1885
9. AGE

YEARS: 69
MONTHS: 11
DAYS: 3
IF UNDER 24 HRS
Hours:
Mins:

10 a. USUAL OCCUPATION: (Give kind of work done during most of working life, even if retired): President of Mt. Carmel Center
10 b. KIND OF BUSINESS OR INDUSTRY: President of Mt. Carmel Center
11. BIRTHPLACE: (State or foreign country): Bulgeria
12. FATHER’S NAME: T. Houteff

BIRTHPLACE: Bulgeria

13. MOTHER’S MAIDEN NAME: M. Chenteff

BIRTHPLACE: Bulgeria

14. WAS DECEASED EVER IN U.S. ARMED FORCES? (Yes. No or Unknown): No
(If yes, give war date or dates of service)
15. SOCIAL SECURITY NO.: [BLANK]
16. INFORMANT’S SIGNATURE: Mrs. V Houteff

MEDICAL CERTIFICATION

17. CAUSE OF DEATH
Enter only one cause per line for (a), (b), and (c)
_____________
*This does not mean the mode of dying, such as heart failure, asthenia, etc. It means the disease, injury, or complication which caused death.

I. DISEASE OR CONDITION DIRECTLY LEADING TO DEATH*:

(a) Congestive heart failure

INTERVAL BETWEEN ONSET AND DEATH: 2 yrs.
ANTECEDENTS CAUSES

Morbid conditions, if any, giving rise to the above cause (a) stating the underlying cause last.

DUE TO (b) Arteriosclerotic heart disease

INTERVAL BETWEEN ONSET AND DEATH: 4 yrs.
DUE TO (c) [BLANK]
INTERVAL BETWEEN ONSET AND DEATH: [BLANK]

II. OTHER SIGNIFICANT CONDITIONS

Conditions contributing to the death but not related to the disease or condition causing death. [BLANK]

INTERVAL BETWEEN ONSET AND DEATH: [BLANK]

18 a. DATE OF OPERATION: [BLANK]
18 b. MAJOR FINDINGS OF OPERATION: [BLANK]
19. AUTOPSY? YES NO√
20 a. ACCIDENT SUICIDE HOMICIDE (Specify): [BLANK]
20b. PLACE OF INJURY (e.g., in or about home, farm, factory, street, office bldg., etc.) [BLANK]
20c. (CITY, TOWN, OR PRECINCT NO.) [BLANK] (COUNTY) [BLANK] (STATE) [BLANK]
20d. TIME OF INJURY

(Month) [BLANK](Day) [BLANK](Year) [BLANK](Hour) [BLANK]

20 e. INJURY OCCURRED:

WHILE AT WORK [BLANK] NOT WHILE WORK [BLANK]
20 f. HOW DID INJURY OCCUR? [BLANK]
21. I hereby certify that I attended the deceased from 6 Dec. 1954, to 5 Feb to 1955, that I last saw the deceased alive on 4 Feb, 1955, and that death occurred at 12:05 Am., from the causes and on the date stated above.
22 a. SIGNATURE: M.W Colgin (Degree or title): M.D
22 b. ADDRESS: Waco, Texas
22c. DATE SIGNED: 5 Feb 1955
23 a. BURIAL, CREMATION, REMOVAL (Specify): Removal-Burial
23 b. DATE: Feb. 9, 1955
23c. NAME OF CEMETERY OR CREMATORY: Mt Carmel Center
23d. LOCATION (City, town, or county): McLennan County (State) Texas
24. FUNERAL DIRECTOR’S SIGNATURE: F. M. Compton & Son Chas. D. Roberts
25a. REGISTRAR’S FILE NO.: 82
25 b. DATE REC’D BY LOCAL REGISTRAR: Feb 8, 1955
25 c. REGISTRAR’S SIGNATURE: Margaret Scott
This is to certify that this is a true and correct reproduction of the original record as recorded in this office.
Issued under authority of Sec. 191.051. Health and Safety Code.
ISSUED SEP 15 2003
[Signed]
Gladys Hand, Registrar
Bureau of Vital Statistics
City of Waco, Texas

WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY.
ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE

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