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I NE1A1 ~ERSEV STATE OE?ARTMENT Oi HEALTM ~~~E '
Oo na wnu n tl~s blpek
f CE11?IFICATE Of pEATM t
~ sr~ces 1. NAYF OF yfirrtl lMdsMl IL~rN 2. OATE OF OEATH
BE:UW FOR oECE~o M I I 1 lctm G. SamQnch f k 7
SiATE USE IT~O~t/Mt/ I ~ ~
( o!vtr
I y~ ~k
rE ~cE 15ea CWa a Race 6. M~ hn N~ 11 wder 1 Vr. If uider N Flra 6. ~stt ot Br~A 7. W» dtowa~d evw n US. /1~aeW forpt~
4tf birdidy/
/YeL no or wikia~rl YK ~ wv a Wts! t
j Cou 61 a'" 3/22/19f3 Yes MMII ~
i 8. Br~AW+c~ fSqat o? /or~~ nounerY/ 9. GUtsn W wAn eow~W7 10. Marrud N~twr Wnwd ? 11. Sodal Seomty No. ~
I +
NeM JerSe y U. S. A, w~ o~•««d o s.w~.ae O 150- f 4-8475
Qcs~of r+cE PLAGE OF DEATH 13. USIIAI RESIDENCE (li wnuwtan: res~de~ce belae adrnas~aU
Morr Js •S4~ N. J. b.c~~ Passct Ic
b. Gt11 (Clrek boa ard *w naeel b. City (C~edc bon and *vt iwntl
° Pequannock T°`° Mcyng ~
~ C Nxne d (lf rwt n Iwip~tal a ntOtuuOn rvt tnett addnfi) d. Strett AdQras (fl ~urM. P.O. Addroa) o/ Deceased '
,'~~',~,Ch i l ton Memorlol Hospita! f9 Brookwood Orive ~
i•. u~r ott,w•~ t:b a.~ ea.,. a.:~,~,~r~ a»~.~ ~ s~~a..ei u. e. K~e o~ e~„~ a~,~,~w
Sole~man LiPe Jnsu~cnce' :
,s F,n~..-. w~ ,s. ~wn~r. w.a~ w~ ~E'~"f't~'~"'~°!~`~'nch i k ~
M i// IQm Somanch ik Mcrr Mcr ze/ ~
_ Y Y l9 Brookwood Or. MQyne N.J. f
c.;;sE lB.PART1 ~EATHWASCAUSEOBY fnrronlyonecwarper~n~lorpl.(DI+~OIcI Ilpproa,m~t~,nyr~alp~~w~n
~ ' a wet ol cqd,tpgn ard ~
6mrd~ate Cause (s) ~ '"~t' I %a.I`wirp
~ Ca+dYdwu. d rrY, wAiah Q~~ ~ ~
- ~w nae ln a6or+uur Oue to (b) i
~ 'la1~ rndvy tlyuistr- ~ ~
c~.o + r. ca+ A'M! ewue /asr Dve to (e)
..,o..._i ~o w~u 0
~e+~~rJ ee IApT 11 OTHER SIGNIFICANT CONOITIONS - » yy~y w~~yy 19e . ~
,.+v~~ednr
;s.te On~WI11fd~ ifldt~flT~i11~11~t~lqtO~dlilA~
_ va r~o O res ~ wo p ~
?W. Aa4em Su.cide 1loemcde Urruwwn ~Op. Osu snd Hour ot ~n*w~ 2Qc. Mav ~M~Y Oocurred lEntr ytue N irywy in Part I or oI ltarn /Bl. ~
O 7 ? p
ro tAe Dett aI +~y knowkdye y .
C 20d I~yvy Oonrred 20e Plsa d rqur~ fe~ n a aba~~ Aonr. IOf. GtY. Towm a Lontan CountY Surc
YYA.k at Not YM~k hrm. bcuorY. sonrt, oN:or A~dy. et/
w«k O at vlfork O
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i DE'7T 2I. ~ IiRIIIAlA. ~ C!CliSld if~Of11. MI IO aI7A IitL filM IhOl1.~I i~1~t M ~ /
Gwrn o~on.nee n ~ 4 o R n~ on r?e eia rnrd ~eoK and a tlr ear o~nq tiww~dye. /ro~n ehe cw~as sa~e •
22s_ Cer~~fier's Name ITypt a Arrt belne signi~y bNar) 71b_ 1ia~lry MOn~s ot .
T. ~w~N s~, ri4r ~~~1~.~., ; jj~ _ ~•~y~~
zac sip,.a.tt (awa eaai? > ; 1~j
~ ~ Anend.~P~i = -
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as c ~ r.ss 23a. Bvu; GuA~tan. Rerno+a~ Y~. Cemeteryr a Gamatay N~rne a,} r ;
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rsus ?30. BviN Wte Mo. Wy Yr. Z4a. Funer~l Hame Name 21b. Furra111qne t~ 3
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7/ 13/ 74 Vond erMcr woyne Co l on jQ ~
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ci PT 72 `s ~265~ Rey~itr~r ` i
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