HomeMy WebLinkAbout0023 ; ~x~~ s~t Mursce ~ CERTIFICATE OF DEATH sT~Tt n~t Nurece t •
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SoACEi ~tiVE OF (F~ne) (Mr1J1~) ItaaU 2. Se: 3. DATE OF DtATH
lEtO~~OR pFCF.ASEp
; ST~E`vSE ,T,~.,,P„~~, Walter S. Kaczmarsk M June 28, 196~
?~~CE Cotor or Rxe 3. A~e (r~ y~s. 1/ under ! Yr If ueder Flrs. 6. Date ot BinA fas deeeased et~t in U.S. A:exE }aces)
f~tt ~i~i~r) Nowf s qs or.s N~~. ?u~ ~ o ~ h ~es. ~e. or ral~orwl ll/ yts. t~~e ~ a 6re~ .
11~ O d y o, ~ no
2C ~f' ~ 8. BinApt~ce (5nt~ w Je?~ft~ ~or~try) 9. t~~~s~ ot ~e+~ roW?«r~ !0. ldarried ~J Ye~ec Yarried 0 l l. Social Security \o. ~
Eliz.N.J US .;ao.~a
~ Diraced ~ 13 9-10 - 04 $ 7A ~
RES~oE~+CE 12. PLACE OF DEATH 13. USUAI. RESIt~E~E (II institwion: tesidence bef«e sdaission)
~«~~r Uni on • s.~~ J s. c~,~r Uni on
E. ~o~Q (Check bo: ~ad sin ea~e) t. City~(] (Check boa and ai~e nane)
T E1 i zabe th ~ E1 i zabe th
e. ~la~e o aot m spi~al or ~esiKU~wn ~~ve sc~eet ess d. &rea Address (It rural, P.O. Address)
« 21 S . Second St . -
Instit~ion n t
t~. a. Usual Occupa~ion ivr k~~1 e/ ~rorl lo~r ri~s ~ost oJ ~ror i~~ li/e. eorw iJ rstn~J1 1~. S. Kind o( Business or Industry
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IS- Eathet's ~aae l6. ?loeher's kaiden Na~e
t nisl czm r Katarz na
17. Infor~aat's Na~e and Address
Mrs. Henrietta Kaczmarski 2i S. Second St.Eliz.N.J
. CwusE 18. PART 1 D£ATH rAS CA ~ U BY E~~er o~tr o~e c~rs~ fi~e /or (~1. (+1 ~w1(c1 Ap~vo:iwue ieta~al ~
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ca.tt~~. ~/.,~..~Ki . ~ ` _
an~t .i:e ro +iovt t.i:s Due to I~I
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G.1:+:«. c«. Iyi~a ~.rs~ l.:r poe eo te)
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PART ll OTHER SIGNIFICANT CO'.~DITIOYS
».A.:w~;... 19+. ~as ,utop:Y 19b. lr re:, verc findiet: eoa
cw~.~. ~ perfoemed~ in dete~minin~ cause o( d
Yes 0 \o ~ ~ 1'es :?o
?~~ee or Zpa. Accideat Suicide Nomicide 20b. Due ~nd Hour ot Injary 20e. Fio~r Injury Occurted lEwtes ~~trrt oJ i~jay iw Pa,t ! w 11 oJ Ifrw /
ACCIDEN• Q O O
ro rb~ Ie:~ o/.y 4wovl~Jt~. M
?W_ Injury Occurrcd 20e. Place of lajurp (~.t. rw a~iorf lo~e. 2p(. Ciq. Torn a Lxaeioa Couney Scace
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«kle /~r~, (~vclory. sner~. o//i~e i/ls.. ttc.)
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eROSS e~wss. ?1. 1(ai~cnded, e:amined) the deceased ((roe, on) to u~d last sar
t (hie, ber)ali~e on
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~ ~ De~~b o~crrr~J ~t ow rlr J~re siered.bodr: ol ?o tbe Lest o/ ~r 1wovleJ`t. /i0AlEf tOYtft ff0lfJ.
~ CE~eSUS 22~ Au~nd~ Fh s. lfed. E:am. Coune Ph s.
E ' ?RACT (Y ~ ~ 7 1~ 22b. Address ~ 22c. Da~e 4aned
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~yy . St~fl~[ C 1~ l ~ t~~ l~~ . 1 l ` \ , • ~ /y~~ ~ ~ ~t L ~ .J ~CF
I, ~ 23a. Bw;al, 4eNiioo. x~~.~i . i3e. e~.««r « e«~~«r r~~ ?h. Loeacioo Cicr Stan
~ lSj~ri/y) . 1 /
~ ' Buria St. Gertrude Woodhid z,N.J
~ ~ ?3d- burial Daie afo. Dar Yr. 2~a. Funcra! Howe [~yoe 2~b. Fvnc~a! !lose Addren
i July 2, 1969 Go~ny & Gorny 330 Elizab~th Ave.Eliz.N.J
?dc. Fvnerwl flirectw SiF ve ~ j. Licews \o. ~5~. Resi:uu issuinF Pe~~it - S~Fnatue 2SS. I1+te Rec'd. bp Lotal
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relav.~. • ~ . : . . , .
~ • ~ aocEa Fo~tR~s
~ CITY OF ELIZABETH, N. J. C1.ERK CiitCU1T COURT
~ • ~ RECORD VER~FtEO
~ t~- OFTICE OF REGISTRA~t OF V1TAL STATISTICS ~
~ ~oy 2 12 Si eM i~
~ . ~ ~ R J UN 2 9 1970 ~ .
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2U0442
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~R AT THE FOREGOING IS A TRUE COPY OF A RECORD I~ ~(1' OFFIC~.
THIS; FY TH
~ _~~.F=
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, Rsyistrar o~ Vital Statistits
City Hap. Elizabeth. N. J.
' Q~1~ ~ ~ Warning. Do not acccpt this copy unlcss the raisccl scal of thc
Gity o[ Eli~~l~ctl~. 1i. J. is ~f(ixal hcrcon.
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