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1~Iew Yc~rk State Department ot 8ealth
Dift. N S ~'~C~ OF VITA{. RECOROf
ns.M...~.as,.,w;.M~. CERTIFICATE OF DEATH Ra"~~ N°
1. lIACE OF DEATl1~ SiATE OF NE1M YORK USUAI tE510EMCE (wMn ~cws«l I~nd. 1/ iwuiNt:MS naid~nc~ Mhn
` CO°"" S u f f o 1 k R STATE N ew Y o rk
Taw~ ~~cn~ a courm ~ TowN
Islip ma"v~'
u~ Suffolk Isli
c ein oa vuucu urr oa hiuae b naiA~su .iNi~ fh capo?~M Gwibt
W 8rentwoad ~ O C~
d IIOS1?
A~l OR M~~ «wKWKes. Y~+~ sln~t adde~u er Mahe. w STiEET . IS tEilOENCE ON fA~t ~
iNSnnmoH Go AODt~ 366 Washin ton ve~ES O ~
w?w~ of
s. o~rE t~?«~~ ~a.~ - n»~f
a~i?o~~«r°.~-.y William F. Seidel oun~ June 29 ~r65
SEII COtOR OR RACE 7. StHGIE. AtARRtfD. WIDOWED, li A1AlttED. WlDOWED OR OIYOtCE~. liwt ef
M~ 1 e I Mi h i t t I a~~ED (Sadf~) M,,,s,.a
Married t«~w,~. Kathleen ~uinn
~m
W1TL' Of i~lTM 10. AGE (In r~ms If UNDER 1 11EAR IF UNDER 21 MlS. 11, NITN?IACE (51oN N covwlry) lt CIfl2EN Of WNAi
61
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~ ~ 8rooklyn. New York (
t~s. YSYAI OCCUtAT10N (Giw kind of wort don~ dwi~q w,s~~ of we~ki~p lih, lA. RIND Oi WSINESS Ot INOUSitY
~wa N or:nd)
Policeman Ret) New York Cit Police Oe t
u. fAiMER•s wu~ ~s ~?wn+ee•s ~uwEn wu?~e ~
W ' ' e Pslliagham
~a w~?s occ~?~o ~ ~N u.s. ~EO roecESt i~, socuu ucuein ~+o. ta u,rouw+rs ~oaESS r e n wo o~
~•~»~%:ino~~+'~ one«~'°~~~ 055-24-7431 Kathleen Seidel,a66 Washin ton AveNY ;
t
1!. GWSE Of DEA1M tEwt~r aely on~ mvs~ aw ~ Ibw) INTRVAI ~ETWEEH
/wRT i. OEIITM WAS CAUSEO ~T: Q q,~T ~p p~~ r
~-7 a ` c 1.~ ~~~.n ~ - lt<.a--t ~ ~
1~1A~1EDlATE CAUSE (O) ~~_.Z.a ~^m~ . ~
C~wd•tiMR, H ewp, J .
MrAid N+~ Ns~ M DUE i0 (6) t~- S
~bov~ iwwdol~ ~ -
ew» (e), qef'up ~.1'~-~."1 ~~~'`,1 ~
~~~"'o DUE t0 (d • - ~ ~ -,~c_\. ~ ~ ~
z ?AR? 11. OiHER SICsNIFICANT CONDITIONS CONTRtfUTING TO OEAM WT NOT RELATED ]0. WAS AUT015Y
~ i0 iNE TERMUNAI CONOITION GIYEH tN //ttT 1(aj ~EtfOtMlE~t
~
~'s~~~ ~
a '+~-yr3 ~-~!S• i~ ' v~~ ~/1 ~ c' YES NO ?
~ 2i~. AK1GEtiT, SUK1DEi o~?uc~oE (sr+wM 21L. OESClI~E IIp1M ItUURY OCCURRE~. (EwlK wofw~ d irywr iw ?oA 1~r ?M ll d iN~ Ita i
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111. IWUtY OCCURREO 21•. ?tACE Of IN1u~r (•.o., in w oew~ Ilf. ~MMERE DID Ciy e~ Nww Cwwyr i1~1~
1Mhil~ ~t ~ Nw M/6:b ban~, torw~. /ocbry. str~N. elf7u blJp.. N~)I (?ilUlY OCCIIRt
week a werk
~ I lu?tby tertify tGat 1 otteMded ll~e deceosed J?omL~lc:~191...i~ lo_ ^ 191.>~ tiol ! la.rt ~r tlke
deteared divt oa j~- , 191,.~_, oed tia~ death ~d ot l~n
..1.o,s the ~mRrrr oxd on tka dote s~o~~d abotx. f
I~o. StGNATURE (Dyn~ ~r l:N~) 174. ADDRESS 37a. OJ1TE i1GNED
- w K : r, ~ -s ~ a . ~ _ ~ .i ~ » u , :
~ 2b. ?UCE OF Wt1Al,~~"~"
TI OR tEMOVAt 2~b. IOCATION (CItY, TOWN OR COUNTY S7AtE) 2k. ~ATE OF Wt1Al OR CREMATION ?
~ St C rle5~ ~t~r F~rnin dale New York Jul 3 1965
~ 2!n- S~f. RE_,Of U REGIS~ ON_ ~ 2lb. ApDRESS Of UNDE~TAICER ~
L ~i,~, ` 571 Suffolk Ave., 8rentwood, NY ~
' ISc OF ESiA Lt fNi REGISTRATION HO, 26u. D /IIE~ {r IOCAI 2db. S1 YR60F S R k
= Michael J. Grant uneral Home 1 03
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