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STATE OF NEw JERSEY
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OFFICE OF REGISTRAR OF VITAL STATISTICS
BOROUGH OF GLEN RIDGE, ESSEX COUNTY, NEw JERSEY
This is to Certif~r that th~ ~ollowinp is correctly copied from o record of D~ath in my ofFic~. ~
HAME OF ~ECEASED PLACE OF OEATH DATE OF DEATH ~
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~ Cdl`C~]. SOl'3~ Glen Rid9t, N. J. Ap'!'~~ 26~1957 f
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~ SOCIAL SECURITY NUAABER SEX MARITAL COHDITION DATE OF BIRT AGE
YRS. MOS. DAYS ;
~ F ~arried July 13,1895 6~ '
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PLACE OF BIRTH CAUSE OF OEATH
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N ex Yc~k, N. Y. C~r~b~~l Yntaratio~ ;
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SUPPlE1AENTAL INFORMATION IF ffEATH wAS DUE TO EXTERNAL C#USES f
ACCIOENT, SUICIDE OR HOMICIDE DATE OF OCCURRENCE
~ wNERE DID INJURY OCCURt s~~~h
~ Citr e~ To.m Covntr Stet~ j
~ DID IHJURY OCCUR IN OR ABOUT NOME, ON FARM, IN INDUSTRIAL PIACE, IN PUBLiC PLACEY ~
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~ SP~eifr Tr~ ef PI•e• ~
~ wHILE AT wORKi MEANS OF INJURY ~
~ NAME OF PERSON MtHO CERTIFIED CAUSE QF DEATH AO~RESS 3
~ Robert H. I~Iuller Monto3,~S.r ~t J. ;
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198~5a~i .........................Rpisfror~of Vifol -Stotistics
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ROGER PO~Ti~1?
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Dat~ of Isw~ _ -