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dt~~'~ STATE OF NEW .JERSEY
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OFFICE OF REGISTRAR OF VITAL STATISTICS
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~ ~ ' '~'r ' 'fi Hackettstown Mfarren Count
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. ~ CITY, SOROYGIt OR TOWNlMIr AMD COYNTV
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y that the following is correctly copied from a record of Death in my office.
~ NAME OF DECEASED PLACE OF DEATH DATE OF 4EATH
~ Mansfield Toxnship,
~ Charles C. Ort Yarren Count N.J. December 22 1
j SOCIAL SECURITY NUMBER SEX COLOR MARITAL CONDITION bATE OF BIRTH AGE
YRS. MOS. DAYS
; ~ 147-01-609oA Male ~ihite Harried May 9, 1889 82
y i PLACE OF BIRTH CAUSE OF DEATH
s ~ Mansfield To~nship,
: Miarren Count , N.J. Acute m ocardia2 infarction.
SUPPLEMENTAL INFORMATION IF OEATH WAS DUE TO.EXTERMAL GAUSES
~ i AGCIDENT, SUIGIOE OR HOMICIDE DATE OF OGGURRENCE
~ i SPEGFY
~ NHERE DID INJURY OCCUR?
~ I CITY OR TO'NN COUNTY STATE
~ DID INJURY OCCUR IN OR ABOUT HOME, ON FARM, IN INOUSTRIAL PLACE, IN PUfiLIC PLACE7
i
i SPECIFY TYPE OF PLACE
WHfLE AT WORK~ MEAtvS OF INJURV
NAME OF PERSON WHO CERTIFIEO CAUSE OF DEATr1 ~ A06RE55
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_ ST. LUCti CJUNTY f lA.
P.G:,i" ~?~TRAS Ly"
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~ W ~EB 20 ~ Zs PH Registrar of Vital Statistics
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i 315 Waehington st., Hackettstown, N.J.
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Address
December 23. 1971
; ....................Date of ~Issue'................... r ;
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