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. '~rs45s New York State Departmcnt of Heait6
Diit. Ne-v ORFtCR OF VITAL REGOR03 ~+~~.s)
- To~.~...»as.~..~. CERTIFICATE OF DEATR R~tered N~~ o'o U
1. KACE OF OGTN: STAT! OF NEW YORK 1, US11Al lESIOEMCF (WMr~ d~t~os~d li.~d. If issfilrtimz nsidMC~ b~/eh
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d NAJME OF (lf wst in hospilol M iiqtifufiow. pir~ stt~N ~ss or (ocotip~ w SiREET Tt1 . IS tESIDENCE ON F/1~Mt
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l~ SEX 6. COIOR OR RAtE l7. SINGIE. MARRIEO. WIDOWEp. IF MARRIEp. MftpQWEp pR qypRCEp, Now~ eF
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f. DAT! NRTH 1Q AGE (In ~wn IF UNOER 1 1'EAR •If UNCER 2~ ItlS. ~ 1. ~~RTH?IACE (Saw er fotii~s wwKry) + 12 CIAZEN Ot wMAi
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l~e. IlSUA1 OC 1/?ATION (Giru kind o~rork don~ duriny wwst of wor4i~g lif~, 1]b. KINO OF WSINESS O[ INDUSI~
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11. fATMEt'S NAME 1S MOTMER'S MWOEN NAME ~
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16. WAS EASEp E1/~ 1!f U_S. ARMEO FORCES? 1~ 50CIAl SECURI~Y NO, tR INFORAtANTi NAAtE ADORESS
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1! CAUSE OF DEATH (fnhr a~lr an~ ows~ on o lin~) IMEtVAI ~FiMIEEN
~ART 1. DEAiM WAS UUSED ~tt: ~ ~ pN~ µp p~TM
iN1Ad~iiA?E CJlUSE tes -
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= MRi 11. OiNEt SIGNIitCANT tOtvDIT~ONS GONTt~~1ltING i0 DEATM ~UT ?JOT REIAtFD ~ WAS AYTOrST
~ TO iME TERAAIHAI CONDITION GIVEN IN ?ART 1(~ ~R/OfMEOt
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~ 11~. ACCIDEHT. SYICIOE. MOMICIDE (Sp~ci/p) 21b. DESC~1{E HOW IWURY OCCUt~ED. (Ewhr wdwr~ d i~j~wr iw IeA !~r Iorf !1 d~ lOl.)
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41d. IW1lRY OCGUtREO 21~. IIAtE Of IHIURV (~A., in w osout 11i. WNEtE CtD G1r w brre Cow~h i1M~
Whib a~ ~ No~ Whib I han~, fw~s, foc~wY, stnN, e1Fit~ bl~~_. ~It)~ INIURT OCCIRI
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~ I lK,sby eesliJy ~hae_IptteKded fhe dec~ased J•om 19 to_ 19-.fko~ ! lart sonv N~s
deuasrd divr on!
~~r , 19_ aed t6a~ death otcxsred ot 7•'~~ rwn t~e cowet ond o~ tht dafe sta~ed eborx.
SIGNA RE IGMn~ w eiN~) 37b. ADDlESS ~ OiATE 31GNED
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2b. ?tACf Of WRIAI, CtFMIlTIpN OR REMOVAL 2rb• 10CAi1pN (CITY, TOWN OR COUNTY AND SiAif) 1k DATE Of WRIAI OR UEAtAT10N
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GlL1T~?RE'pf tT ER REGISTRATION NO. 2lb. ADDRE OF UNDERT/1[
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NAM,/Of ESTA~{,IISHME REGISTtp110N NO. 260. DATE fllE~ ~ LOCA~ s(^ REGISTRAR
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