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NEMf JERSEY STATE DEPARTMENT OF HEALTH V~ y.. ~
LOCA~, i1LE MUMOEN CERTIFICATE OF OEATH STArE F~LE NUwBEA '
Lsv~cES NA.NE OF (Fi?sll (MilJ/t) (Lasd 2. Se: DA7E OF DEATH 1 j
~e~o~~on DECEASE~ ~ ~ ~
STATE USE ~Tr~ o, p„~~~ ~t , •
G1:lV
PLACE Color ot Race S. A~e /rw yrs. If under 1 Yr. It wder 2~ Hrs. 6. Dxe d Binb 7. ~rs deceased e~er in U-5. Ar~ed Forcea~ ~
, ` l~sf 8irtblt~) Alwt s Dars Hwvs M~~. / O~ (Yes. wo. ~4wow) (f/ Y~s. a~4e r~r or l~res o/ tt?v.l '
~S ~ T ' .
B. BinAplace ISt~fr a/oaire cor~tryl 9. Ciiiuo o( ~hu couacry) 10. 1larried ~ Nevcr Harried ~ 11. Social Securi~r No.
(J ~G/~R f- V s. fido~rcd Dir«ced ~ IS ~~d -?IS j
RES!DENCE 12. PLACE OE DEATH ' 13. USUAL RESIDENCE (If ias~itutiae: resideace ~e(ore ~d~issioe) '
c~~~ UN l ~/v s~~~ S. Countr t>l~//OX ~
b. Ci~Y ~{J (CAeck bo: and ~i~e nase) e. Citr~ ~ (CMck Do: and ai~e n~ee) ~ t
~~o~~ ~.q/3 ~'r ~Y - T~°~~ ~ ~
c. \ame o (1 no~ m spital o~ ioscitutioo 6j~e screec ess d. Sata Addreas nrd, P.O. Addteas)
~P `Y R .
i~~"~«~~~! X. G£ I o!a ORC~/
l~. a. Usual Occupataa G~vr t~ o/ rv.! Jo~e dr.i~a ~osr o/ vo?lr~a l~/e. eve~ nh?e!) 11. b. Kind d ousio?es a lodusery -
u~,/~ oPFR•¢ro~ ~ ~'~fc, S To.p~a6E
tS. FaeAer's hane 16. Wo~her's Maidea Na~e
s r t~ s- f~N~rA ~ ~ Q.9s ~
17. IiJornane's Naee and Address ~ ~ ~
C~~ ~/A !i?O TE.t,/d o //~/~b £~t! /Y , ~
c~use ~8. PART 1 DEATH ~AS CAUSED BY E~tar wfr we c~rse ter li~e /a I~), (i al (c) Approaioue intena! berieen
_ 1 ~ ~ ~ 4
Issediatt Cause -
i y /
~f Cowlitiws, i/ ar. rbicb ~ ~ 1 C~~ , ^o -
riss to rbove c~rse ~ ro(~) v`~~'
f
- 'Y~1". st~taa tb~ ra/er-
E ~.ens con. ~i~ c~afe last [~e to fe1 ' .
~ . _.~,_o ro e..M
~ ~~~0~~~ PART II 0?NER SIGNIEICANT COKDITIONS 19a. tas ~ut s 19b. U es, ~erc fndin s considned
.,~T.~~a• oP 7 1 t d
~ , pedo ? in deeemin' cause of deatA~ .
Ycs No ~ Yes No C7
~ o. , c c or p~_ Acciden~ Suicide Haaicide 20b. Date and Hour of Injur~ 20c. Fb~r Injury Otcutted IEw tr w~trrt of ~~ryry rw P~rt 1 11 0/ Ite~ Id)_ '
•CC~O[NT Q ~ O
~ fo tbe ~rst o/ wr ~warfel e. . ~
~ 20d. Injury Qccvrred IOe. Place o( injuryfe.a. rw o. rborr bo.ee. 20(. Ciq, Toro or Locatiao Couotr Seue ~
i ~ile at ~\a s'hile /ow, /~ctory. shre~. o//ice b!ls.. etc.)
~ ~'ork u {'wk
~ ss c ~~ss. 21. I(auended, e:ami d ehcdeceased (tro~, oo) 1~~ to aod I~st s~r (biw. Mee~~ti~e on
~ _ Dsatb occrnel ~t w_ w tbt l~te sttt~d ~ vr; and to tbe brst oJ ~y 4~wrldat. Jro~ tbe t~rses sutrl.
~e~.sus 22~ Att~ndiQ pb s. Ikd. E:a~. Couot P6 s.
*~~cs 6 1~ ~ ~ Y f O 22b. Address 22c. a Sis cd ~
~ s~e~~~,~~ Z ' /C% l(i 'N~-~ ~ ` ~ i ~
~ I3a. Burial. 23b. Cesetery a Creeaacory Nase ;c. ui Ciq &ue ~
!S jeci/r1 '
~ S r,~o S£Ay G~ Y/~ ~TGp~ 1~/~s l vS~ ~ tJ: -
23d. Burial Da~e No. Dar Yt. 24a.. Fuoeral Home Naoe 24b. Fnner~! Ho~e Addres
~ S - g ' ~ ~ ~ E F~N ~r~,~.~ /yo^`i E .L i ~v,D ~ iv ~ c7~ ~
~ 2 r Directar Siaoanre N. . Lic e No. 25~. Re isa~r Is in ee~it - Sisonuce ZSb. Date Ree'd. b~ Lonl ~
~ ~ ~ Reaisaar ~ ~ . s
~ a~~. A aa :
~ 1A11. . ~ ~ ~
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~ FILED ~~~D PECORDED r :
~ aF . C1TY OF ELIZABETH, N. J. c_ LuC~~ ~aU~~TY. FLA.
`s r y~ %a' y , . ~OFFICE OF REGISTRAR OF VITAL STATISTIGS' - ' - ~ ~ ~ ~ r .
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_ r _ ~ -~9 ROV I 4 AM 5 3~
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~ELI 1' • '~C~,~
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THIS IS TO CERTIFY THAT THE FOREGOING IS A TRUE COPY OF~~~I~F.G~~~UI,~Q ¢QV~~FICE. ~
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Reyistrar ot Vital Stati~tiu •
~ City Hsll, Eli:ab~th, N. j
Warning: Do not accept thu copy unless the raised aeal of the U R 1~i(1 ''J :
' City of Elizabeth, N. j: is af[ixecl hereon. BOOK 1v1 ~'ACE ~ 1
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