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d~sr~~ STATE OF NEW .~ERSEY
~ OFFICE OF REGISTRAR OF VITAL STATISTICS
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Tbis is to Cert~/y e4u e4e follo~rln~ is oocrecdy c~oQied i~ a recocd of Deae6 ia ~r o~flee.
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SOCIAL SECURITY NYMOER SEX COLOR M TAI. COND ION OATE OF AfiE
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SUPPlDr1EMTAL INFORMATION IF D[ATN WA= TO CAUSE~
ACCIDENT. SUIGI~E OR lIOMICIDE O~Tt Of OGCIJIqtENCE
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~ WMILE AT 1NORKT - MGN~ OF (NJIMY
~ NAME Of PERSON 1NM0 CERTIF CAUSE OF OEATM ADDRESf
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ReSIs ot Vltal Satisti
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Address
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