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HomeMy WebLinkAbout2553 ~ . , , , ~ E~A!C'a ~F H~ALTH , j ~ -~Y- ' FtITHEFF~RU, N.J. . s ~~4~ ~<t ~ ' ~"'y~•t. ~ , r .u~' ~ T s ~i~y~ J U l 2 31974 - ~ ~ ~ 4. . e~:~ s~.. i e ~ `K+~,1.M{ 4 ~ . • • , ~ • ~ • . ~ ~ ~ ~ A ~ - Thi,~ .i,b .to ceh.ti.~y ~haat ~he ~oLCou:ing .i,a a ~tt~ue copy ~ - o ~ a neco~c~d 6.i.eed .in #h~,a depa~r,~en.t. . . ' ' 1 . • Fi~.Ea F:co?~oEO - ~ ~~lO• .~ti:l•~ gT.IUC:: C"L~NTY ft . RU~'.f. : ~ ~ ~TRAS c~~ r~~. ~ouAt eg o O~ i oE~- ~ . ~~~M~~a~ iTATEfIIfNtiY~l11 ~ ~ YENf JERSEYSTATE OEPARTaIENTOF HEA~TN •~V I I ~ Y~ PM'~~ CEHTIFICATE Oi DEATN ~aces t 1. 7V~ttE CF (firul lAIw~N lLud Z.OAiE OF UEATH . eE~vweoa OfCEA5E0 • sraTe t,Sc /Ty/n0?MHrfJ ~~?~/7 ~ V . ~ - pr~v + rz 3te • 3. Ss~ t Cobr a Wa 5. /I~ /in M II Yf10N ~ Yf. I~ IMdN 2~ Hf1• 6 OsK a Bir~ 7. Wu ~vu in US. Arawd Fpces~ . fbn~ht Qtit /tars AIn ` fYa~ no er autn~wwl f// Yeq, j~r wra?dier! . ~ I f3n.o ~.1~ / o?/. rJ~~7~ ~7t~ • 8 BM~hysce fSna a torwln counary/ 9_ C~uxn d rhat eounay~ 1Q Mxned Ne,er Marr~ed I1. Sodat Seaw~qr I.u. : l, ~ ' Wdow~d Q dro.ad Q Sepsatad Q - j; AlG ~ S . F~ . ~ . s~oetice ~Z vu?ce oc oewni _ i~. usuw~ ae.sioeNCE ~aua+:.hd.~« b.ro•. sa~:s:o~~ . ~ ~ ~R CN ~ sae. c°un~' ' ?3~i~ ~ ' ~ - e. Gqr ~ ~.~ud~ eos .~a 4.e ~wn.) b. C:tY ~(9w! boi r+d ) ~ - T..R~ U~ lI.7~lC "O ~ 7.ro. ~~G M S C NyM ~ (11 oot :n nosp~ irotinirion 9~w sae+t addier) d. Swet AdMe~s Ilf nrar. PA. Addren) of Occ~wd llwptal o~ ' Inst.n,non O O ta. a. uwa~ Occ~v.6on lG~re t:ne e/ wo.t dar d~..:ny mos~ o/.o+t:n~ ph, e.w. a.enndl 1!. b. Knd of 8usimw w Ind~ntry i c~ / ~42~ ia-~ • C - ~ 15. Fatl+ers Name 16. Abd+er's IAaden Nsnw 17. Infa~nYs N~+e ard Addre~a } ~~~y. ?o ~7 i? O ~`A f/f C~Q//Y~ P ~'Li ~Oi? O~ ~ - ~ z,;_ 18. YAR T 1 DEATH WAS CAUSEO BY Enter pdy one taisr pr 1i~e !or /aj. !bl ar~'1 kl Approaeut: nqna~ D~r.wen ' C.~ • ~ ~ ~Z~ rS a.~a~ I M~~n. c~,. t~t v~ C r ~ ~ ~ cc~rf:oan+~:?~rr wA:cA O~e to (b) ~ - garerif~toa0owcwn~ !+1" tr+6ny tlMundr ! i<~~ :.o-n ca~- /y,~y tsva~ hrI Ovt to k) . ~.~g co M.Y~ ~ .,..,.o .e' r:. .r r. OTii~~ $IGHIflC.iN7 CO~iJITIO.YS , i~,. was w,~ovw tise. i~ re+...... w,e~. oo~+~e«.a ~..as.. O~~on*Kd~ ind~twnwrrycaweotd:aNi ~ ~ Yes 0 No ? Ya Q ~p ~ ZOa. Aeerlent Su.d~de Hoemeid~ UNenown 20b_ Dsee and Flour W Injwy 20e.11ow IoNY Oeev~ed /fnew ry[~rrd iryewy in P~rt! o?1f o/ /m~n Idl. ? ? ? ? ' - ro rAe Onr d my 4nnn4d}r ~ M. 2:i!- 1^iwr Occwnd 20e. Pba of :~urY /eg bn oraDaitAa~r. 20f_ GtY. Tw~n a Lout.on County . State ~ rihde at Not NMte /ann. ~xrory, saM oNK+e Mdl. ~u~1 ' ~ Y:wk ? st MGack i': - 4 r Oc 21. i iutts~dM, etnn:n~dl IM d~ceawd (from.e+) ~ to ~ _and last tsw prw. Atr) d%+rt an r7 ~ 7~J ~ :c v' _ ~ lYitl~ oecwnd at m. pr d+e dsn st~ted abore, and b tAe Det~ ol 4nowt2d~r, /ian fhe tausn anpd ~ ~ 22a C!~I~~~?~ S N3T~ /Trr. o~iimt Detye s~rnq Eei:iwr) Y2O. fia..mg AdO~ess of C.r~f . i ~ _ t ~~~~~~L (T ~91~,~5~'~k. ~ 2 v G ~ /is~s~~ ~J~~ T~o~~~~" ~ ~ I 22: S~~aarr ' (p~k po~) ?1d Oite S.r~ed • ~ ~ " ~ ~ Atterd~ny PArs~ _ Z ~ ` ~ lu~' - E.~,. ~ '7 L - 7 y ~ ~r~:.?S ~"!3, C•~•-3.Gem,non,H.n~.a1` 23o.Ge:n-tryorGt:ni1 Nimr ?.3r.l.o~~t.on G[Y S~r.e /S~AC~/ [ ~ . _~u . s3 ° ~ ic-/,t/~e s ~i» e T~.e - ~St~ c~ .~'i ~i~~-~~.is~c-~r ~i } i I?'s: F; a~ Da-~ 16SO. ~ Uri Yr. 23a fw~e•at Hocn- f~~me 27b. fun-rN l4xne /~Ltr-r, ' ~ ° y~.Qi» rs ,t~.~~ ~ - - ( , •.1'? .x 17~ ~ot~aAS ~ ~ 1, v~e~r,o t~ ~..r ` r ~ ~ g `~Ft,•. ~ f~ ,..y S~i~~turr N.J. C~..e~rs~ t~o. ?Si rq~ttrar IcwNrr~Pc+rt:~t - Sanque IaS- O~t! Rx'd b~ t o:al ~ . - - ti ~~~if}j'.-1.~ ~ ~(7,~0 ~~tX~-+.~ ~•~`:_ticc-l'-~-~-' R~q'e'a' ~.~.3• ~''1c % ~ . n ~ ~ ~ c g~z~5 ~z~~o ~ ~ _ _ ~ . : _ _ _ _ _ _ ~ ~ ~ . s~ -