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Y~rifl~d Transcript of D~oth 131 M/illiansa+ Law Book Co., RoeM~eK 9, ?i.Y.
~ Verified T~anscript from the Register of Deat~ ~ t
Namr of Dtcwstd
Dat~ of DwtFi 2+=~ r'~ R~qiatir Ne. 5Er~3
(MoMt~) (Dar) (Ywr)
Plae~ af D~ati~
l.~nq~h nf Stor
In Town, Citr or Villaq~
Racs or Co{or ~ Sex . . -
Sinqla 'Marri~d ~ 1lidaw~d Divore~d - . •
Ag~: Ywes '~y A4oaths...~ DaYs _ _
Saciai S~curitr No. ~ih~^r~""l~~
Mar Y~teran ( ii yos, what wa~) D
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Occvpation
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t)a
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Citix•n of Whot Counnr ~ ,
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FethK's Na~n• ~ . ` J -
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MoaF+sr's UAoidsn Ncme
~ause of D q1It If11~fYOI BYh1I~M
Onx~t ahd b+wt~
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Al~dical Attsndas~c~ w otF~~r Attondmt ~ +~=~s
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Ploc~ 04 Buria) ~ ~~a ~s ~
I Mr~by salemn ir ottssf that fhir is a trw teanstrlpt kww tM it~qistw of D+aths k~pt
in tM ~R1 f~ ~~l
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Cow+tr of :5io» of Nsv? Yo.k
Das~d at ~~~IlRtrA'~ 11~ . +ih rf.. t*L~i 19 ~
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