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~~(~1Q J DEATH CERTIFICATE
EDV~'ARD H . STAhTON
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~.A~ STATE OF NEW J ERSEY No.....,. 3.~ .
s ' OFFICE OF REGISTRAR OF VfTAL STATISTICS
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City. Botoua6 or Tovoship and Comty
Tbis is to Certi/y that the folloaing is correcdy copied fcom a record of Deat6 in my office.
- NAtAE OF DECEASED PLACE OF DEATH DATE OF DEATH
Bld~tan+8 H. 8tantoa ~utlay, li. J. Jtzlp 10. 1974
SOCIAL SEGURITY NUMBER SEX GOLOR MARITAL CONOITlON DATE OF BIRTH AGE
144 ~14 9703 Maie t,~its Marri,~d 1~ 9:. Mo~. AYf
PLACE OF BIRTH CAUSE OF DEATH
Illiuois Acube l~yocaz+31a1 ~tarctiaa ~
SUPPLEMENTAL INFORMATION IF ~EATH WAS DUE TO EXTERHAL CAUSES
ACCIDENT. SUICIOE OR MOMICIDE DATE OF OCCURRENCE
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WHERE DIO INJURY OCCUR? + ~
i eKt o~ towr courrr sTw~c
DID INJURY OCGUR IN OR ABOUT HOME. ON FARM. IN INDUSTRIAL PU?CE, IN PUBLIC PLACE?
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i WHI~E AT WORK? MEANS OF INJURY
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I NAME OP PERSON WHO CERTIFIEO GAUSE OF DEATH ADDRESS •
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i Albest L. G~os, N. D. 225 Hi1183s1s l,v~e., Nut]rsy, N. J.
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~ Registrar of Vital Statistics
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~ Ta~af Hall, Nutl~y, N. J.
Address
Septreaber 24, 1974 .
Date of Iss~e
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