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Na ?1 Cha~. B. eoushWin~. Publisber. S~ Be~ver 3t». Aibany. N. Y 1P207 ~
A Verified Transcri t from the Register of Deaths ~
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~ Date of Death _ ~+l~_~s~~9_ Regiatered No. _ . ~
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Place of Death - a~l - ~l- ~!!s- ~n!~ - T'- - - - ~
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Nameof Deceased ~~x-~--•--•--------- ~
Age.---~-------Years, --•=--------Months, Days
Sex- ~--------C,oloror R,ace-----------~~
Single, Married, Widowed or Divorced . _ _ _ _ _ _ _ ~S±!~_ _ _ _ _ _ _ . -
F'ull Name of Iiusband or Wife. _ _ _~!l_ t~_ _ _ _ _ _ _ _ _
Date of Birth _O~tRA~! .LZ~3,'~Q'~_ Birthplace _ _ _ . _ _ ~
Citizen of whatCountry -------II. i.-j`--------------------• ~
Occupation---- S.S.No.-------
Father's Name ?ho!!a!-l~iii
, Mother'sMaidenName---------~b!~!
; If Veteran, Nameof War
Cause of Immediate Cause _ ~u ~
!i?:fdibl+~ ! ~ioa! o~~ lfoi~~i ~ i
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Death Due to: s
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' ~ Time Dr, in Attendance ~ '
~ ~ till Death ~ - ~
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~ Medical Attendant or other~ Attestant _L!_ ~!!~t ;
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j Ptace of Burial I~~ ~~~i1_ C!!_
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` Undertaker _
` j~~iqii P~alo~~, ~ocot~ ~i~ii ?attt '
~ ~~crcbq SQtcmniy Httcet, That this is a true Transcript from the
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~ Public Register of Death as kept in the office of Town Clerk
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i TOWN OF MOUNT PLEASANT, NEW YORK
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County of WESTCHESTEK, State of New York f
_ - , 25~21
; Dated at North Tarryto~;;~~*`~ork
> fILED AMp RECOROE~
; ° ST. LUCIE COUMTI' ftA.
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' ' • f ' ~ EROCE~ PO~THA
~ • - Ct K CrR~UIT COURT
s the---- 6t1~---_-; t~&y 0~' ~ ECORDV,~~rrE
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~ ( Signed ) - o~ MAr 26 aH'13
; . ' - ; : ~ ~ ~~Registrar ~ ~ ~i
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