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A Verified Ti•anscript from the Register of Deaths.
D:iteof Death ........................~Iu~Y...~~~...~.~~25................................................Registered No...........`~~~...................... ;
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\~ime of Deceased ................s~.~~....`~~~.......................................................................................................................
Date of Birth ........................~~~?~.L~~X'Y..a.~ ~...~~7.................................................. Age.............~~............................ :
Sin le. Married. ~Vido~ved or Divoreed..~~4lCT.~.~d F'I~u ~ oR
~ T M w ....................S~~r~~~~
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NTY ~ D......
E ull l~ame of Husband or Wife ...............~.~~,~~4~4~~~i~.....CD4 {~E}•~,'~'~IF?~ LA:
...........~L6`. Eo
.....................4~?~-~.4~4a9#~............._........................67...N~...20..1W 8~8
Social Security No. . ~ ~s•
C'olor or Race if other than ~i/hite..........~~#c4 _.l'i: ~
If Veteran. Name of ~'ar H4...............................................................~~;ERK.C.IRE(t1T` CO -
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~~cupation Ga~s~en~r.. -...Har.x i~.ul~.ur.e.-Gommnrcial...n~u~rser..y..................
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Birth lace $C.Q#c~~4I~S~......:..................................
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Citizen of what Cauntry ..........................U.r.s*A~............................................................................................................... :
, Father's :1Tame ~a.43~~4.Ad~x'...~At~.#~'1~....................................................................................... `
~ ~iother's Name U~~?~Q~......................----.....-•---........................................................_...............
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t Place of Death ..........................................Sy,o83et,.Hospital.~...Syosset,:.N.:.Y-................................
I.ength of Stay in Town. City or Village:.1~.A..A....HOS~1itA1
t'~~use of Immediate Cause ....................A.C11tE...car~dia~..~ai.lur.~..~du~...ta..~d~ranced...c~r.ona~.y..... ~
Death ~ac~c ...................................~r~~ry... dis~as~..~er~.~h.. cnrAn~ry...thr~mhasia...................... - ~
Time Dr. in Attendance .......................~S~rt..hilrl..de,ad..va.................................................................._................. :
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Ju~Y..~..4... .~96~..........................................................................................
:1ledical Attendants, or other Attestant.... Minoru Araki~...M. D. ;
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~cldress .........................................................l~~s~a1~. ~s?t~~;~Y...~~.RuttY..~ed~.C.~~...~~Am~x~~x............................
Placeof Burial ..............................................I~C~tQx'~,a~...G~A4~~~~y..~...~~~.s~..~Sp~.r~B..kla,rk~ox,...H.X,...._......... ~
t'ndertaker ...................................................~mey...~?lxn.~~ra~...klA~oo~.............................................................................. ;
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acidress ......................................•--...:............~~...~lC~'y...I~i7.1..~inas~,...S~cps~et.,..~i.X......................................... _
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~ I HEREBY SOLEMNLY A~'TEST, That this ia a true Transcript from the Public Register of Deaths, as kept ;
ir. the...:...... .........:......:..............~Rl~l...D.~..Dy.~Xr~~...~t.........._...................................................................
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('ounty . ~ tt~ ~ . ..........~A.B~u......................._................................................ Stateof New York
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Dated at .:...:....................................Qy.S~~T...~ly.•••-•••-............................................................................. N. Y.
the . . . . ..................1~~.....................day of............................Dec,embe.z............................ .,19 66
(Signed~ ...................?.t~.c..Q.i
.:.l...ct~......~s~7='~...~:....,~........................................................................ ~
Off'icial Title Deputy...~g g~. S~7C~~'................ ~
J 6~IK1~ PAGE ~JG
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