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I~ \ie•~~ l~ork til:~tt~ Uepartment of Health 3'L
' OFFIC~E OF VITAL RECORDS
I D~.t, ti~. C E R T I F I C:~1'T E O F D E AT H Registered No.__~_-
~ ~ To b~ ~n»rted bv rp~ilrar - - -
~ F 1. PLACE OF DEATM: STATE OF NEW YORK v USUAL RESIDENCE (Wh~~~ decw+~d iir~d. if institvfion: rtsid~nc~ bsfor~
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A~, I~ a. COJNiY a. STATE odmi~sion).
~ i~ Nenr Yt'~ic ~ - -
0.! J b. TOwH • IENGTH oF ; b. GOUNT/ c. TOwN
(a~1 ~ STAY IN TOWN,
F+ I~ - ~ - --I UTl' OR VItIAGE I~ ~ j~~}~}~jr
~ c. C11Y OR VIIIAGE d. CITY OR YIILAGE ~s r~ti~d~nu .+lth~n itt tOrporab Gmifs?
.tn. ~ - p~~i~~ii~i" I ~ ~ ~Yi
~ - YES~ NO ~ -
• ~ ~ r ~ d. NAME OF (If noT in hos itol o~ intlitution, ' --T if. IS RESIDENCE ON FARM?
~ p g~.~ straH addnis or luotion)~! STRfET
, . FiOSPIiAt OR y~ V y~~ i: ADPRESS
• O II INSTITUTIGN ~V~N ;1~{~_ _ ~ ~~1~ I ~ES N~
^ • i 3. NAME OF - - DATE (Month) (Dor) (Tw~)
' ~ ~ ~ DECEASFD y~ ~.py.yp v, D/~~p n T~ I OF
h~ , (Trp~ or Print) _ M 111~iL11.J~A ~ l7LiL~A.it r~in:iL 1 DEATN J~~ 19 ~
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SEX ; 6. tOIOR OR RACE I SINGIE, MARRIED, WIDOWED, i 8. IF MARRIED, WIDOWED OR DIYORCED, Nam~ oi
z , `ti' DIVORCED (Sp~cify) I M~sband
~ ~ r (er) Wif~
~ ~ Feoali ~ !~#a-~ ~'1~~ld chsrl~ s.dg~d~_
~i 9. DATE OF 61RTH ~ 10. ~GE !In y~ors .IF UNDEf?I YEAR IF UkDER 2~ MRS., 11. 61RTMPUCE (Star~ or forn9n covnfry) 1. CITIZEH OF WMAT
losf bu~ ay, - - I tOUNTRY?
~ ~ s G ~ Hourf ~ M,r.
~ ~ ~~.e _.1~_ 1,903 i ~ - ~ ~ - ~ - ~ - ~C~i~
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13a. USUAI OCCUPATION ;Girs lcind of work done dutinq mosl of wori~np lif~, ~ 176. KIND Of OUS~NESS INDUSTRT
Q ~ ~ V ~ ~ __J'• •~m if nhr~d; ! ~ v~
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C . _ _
~ _ 11. FATMER'S NAME I5. MOTHER'S MAIQEN NAME
~ ~ ~ '+~Z'itf~C S~~' JaAA ~'IG~'giTf
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r ~ 16. WAS DECEASED EVER IN U.S. ARMED FORCES? i7. SOCIAI SECURITT NO. 16. INFORAAANT'S NAME ADDRE55
~y ~ G (Y~~, no, or i;lf y~~, yirs war or datei of service; I
~ a ~ ~ ~nknow ~
IN7ERVAL lETWEEld
~ 0 19. CAUSE Of DEATM iEnhr only on~ mus~ on o lin~)
~ V~~ PAAT L DEATH WAS UUSED BY: ,t ~ ONSEj AND'JEATH
w ~ ~ 0 ~ IMMEDIATE GAUSE ;a) _-_-~~t"M'~~ti~' at ii~r -~,_~A•
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~ W w > ca~d;r~o~.. ~r a,,.. ro~ *~'~r_
~~r Q~i ~ which par~ rii~ /o i DUE TO iS) ~ u~
u,a pbovi imm~iaf~
Z~ QQ 7 ~ cvusl (a), sfafinp ~ -7~
tM und~rlyiny O -
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~ v i~ ?ART I1. OTMER $IGNIFICAlJT CONDITIONS CON~RIEUiING TO DEATH BUT NOT REIATED ~ 20. E I~~ST
~ " TO TNE TERMINAL CONDITIOtJ GtVEN IN PART I;o) ~
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~ 21n. ACCjOENT, SWCIDE, MOMiCi~E (Sp~c1/~) 21b. DESCRI6E HOW INIURY OCCURItED. (En1er natvr~ of ~nj rvFo~l I or /~f 1 of i~ 19
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CD Q ~ 1 I Mour Mo ~ Dv Ywr~--'• ~ _ ~ ~ Q rn
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~ ~ / , p' 'n' • ~ - ° ~ ~ _
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Rltl. 1 JURY OGCURRED 21~. PIACE OF INIURY ;~.q., ~n or abcut 21f. M'HERE ~ID Cityerhvn Cov StaN
~ d i~] Wbil~ a1 No1 Whi~a ~ i homo, (orm, fostory, err~N, oli~u bidy., ~k.)I INJURY OCCUIT ~ ~
z Q ..l M(ork a1 Work i ~ r
kestoy cer~if•J that 1 atteredid f%:e deiLea';.rd )•az~ 19_._ to-- - , last saw the
r ~ c`~ ~ 2 5~ 19 un~ thn: death otnnwed ot~~_ from thr cor.rrs and an 1lit~nte statrd abovt.
~ decenrtd adire on_
_ ~ 430. SIGNATURE (Ospr~~ or f~rf~) 2~b. AD[)RESS I Zk. DATE SIGNED
` ~ H m ~av3d A. W. Wil~on K. D. I L6 P~ah~a~ st. H. Y, Uu~e 28 ~961t
f ~ q 240. PUCE OF BURUI, CREMATION OR REMO~/Al 2tb. LOCATION (UTY, TOWN O~! GOUNTY AND STATE) Y1c. DA~E OF EURUL OR CREMATION
c ~ S~ t~nMOOd Uniaa C~w N~ ?o~ic Ju~ 29s ~26~l~-- -
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~ 23a. SIGNATURE OF UNDERTAlCER kEGISTRATION NO. 45b. ADDRE55 OF UNOERTAKER
~d~ward Fitssi~ahs H01332 036 9oat?o~ Poet Rd. Ry~ t~r Tae~lc
:Sc. NAME OF ESTAELISHMEt1T REGISTRATION FiO. 26c. ~AiE fItED 6Y LO-C.~µ ~ 26b. 31GNATURE Of REGlSTRAR
' H. t3r~ha~ "~t~s F~eral Iiarr" 43099 Jtiwo 29, 19~4 Doa~ot~ R. Brtioo
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Evrial w( V~rmit Isr~ed by ~`~~6Y BOOK of lasw 3~4 .J~ ~.S 19
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