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HomeMy WebLinkAbout0088 ST~L~i;.~h: jhTr~~lA ~ ~ ~ q.- ?R45 ~tE~~ ':~::~,'::c~Rt DEPARTMENT OF HEALTH 34tI21.~ ~ Af ' ~ f ~f ~ ~ POINT PLEASANT, NEW JERSEY 0874~ ~ ~;1.~;~ ~ Ju~ 1 I 1103 PN b7 ~ ~ lUate~ July: 14, 1976 34021g - NOTE: If this is a copy of a birth record, any agreement of or difference ~tween tl+e chitd's surnams and the wmame of its tather does not imply lepitimacy or itleyitrnaey, This is merely a copy of the information wpplied fo~ prepsration of U~~ o?iqinN birth • certificate. THIS IS TO CERTIFY TNAT THE FO~IOWING IS A TRUE COPY OF A RECORD FILED 1N THIS DEPARTMENT. ~ Re trar o itol Sta~rrtres ;..,r,VIt~G: DO NOT ACCEPT THIS COPY UNLESS THE RAISEO SEAL F THE REG(STRAR OF ViTAL STATISTICS IS AFFIXED H EON. ~a~i •~~t MyM~tA CERTIFICATE OF OEATN AZ~'~IIE MUY~[A 3l~.L 6 tv?c~f 1. NAN?. I1F IF~nN (M~1/trl fL~a~l l. Sc¦ l. UATE Oi DEA7H st. a¦ ~o~ UF( EASFD _ ~ ' I e ~ ~ , ~ 'r~i[ u![ (7~~~ p~ y~i~t1 . Q/L(~(/i ~~Kice C+l? r~~G[ 1. Color o~ R~te ARt (i~ )~s 11 und~~ 1 1'r. II un.f~r :1 H~s. 4. Ua:a ol l1u~A ias dettased tvr~ in U.S. Arsrd Fatr~~ . ~t ~ lul~jA1~>1 Muwr s P~~s /lory M~~. fYei.7~. nlwo~.wl !1/ trt,_, n~ w~~ I"~l~s ~./~~rr.l 1 w w 2 a. [i~t~A`lac~ ISt~t~ w fo~nsw ruww~•r/ 9- Gu:tn of ~Aa~ cornuy~ 10. U1arn~d j~Nr.rr 11au~~d 11. So~.al Srcun~r No. ( ~A s'~dnrtd ; ) D~•«c ed { ' } ~~"V~~S Ke~z N• a• - - - Ct Il. NL At E uF UEAT~f IS. U~UAL RF:SIIIF N( F(11 ~~su~w~on: ~rs.dance arlore .d+w~ss~oa) co~~~r ~cecve e. c~„My /1b~tmc~ttf/L C~~~ ~ ~ ~O~ /_~hrck tw~ ~ R~r~ eaiwt) t. ( ~~r ~ ~ ~ hrak bna ~nd ~~~e naat) Haro ~ e,(j~Q~t{LC No~nr ~ 7 T` _ c. N~M ol 11 no~ m o~pud o~ ~nsn~~uoe R.~~ su~n ad.fressl d. Juc~~ AdA~~as (ll rurd. P.O. Add~ass) ~ '~°.r~•' Y'v.i~,t P.lea.ean.t Noe . (3each~'irvn,t i` ~~.~,~W~o~ 1{_ I~+wl (l~cup~~wn 4n~~ ~.w1..? ro.~ Juwr ~r~~wR nos~ uJ rw~~w~ /iJ~. ~ivw ~~A.rll i~. b. I~ind o1 8~srnris a Ind~sur O ~(.~..(.~.~[~f/L IS. is~6er'+ Name !6. Mo~Ae~'s I~/~~den Nune . Ce~vu.e T. F. Ne~cl.ih;e ' ~lach i). Inlor~n~n~'s Nsne ~e~d Addtss ALie. Sv.ra !3. Ne~r,CJce 7j !ljeach ~r,~, I? N• CwuSE I8. PART 1 OEA'fN ~'ASCAUSf.O HY FA~ r p~f~ owi ~rrs~ ph l.wt /w (~1. l~t~~ Irl ' ~~proa~n~a~e ~ntcr.~3 Ae~.ete ~ onst~ and AestA ~ f • ~ i ~ ~ ~ > •-_.f~/+r'i' ~i_ /7.. • : ? ^ . I~edu~e Causa fil • y ConJi~~ons rf ~wr. rb~t~ p~ to f~1 . ~ r.a~ ~o ~8ove c+rsr _ '"t~l". s~~r.ws ~Ar Mbr. ~ . r_~....... lr~~~ c~r~i bu Due w f~/ ~ - PART 11 O'TiIER SIGNIFICANT f Of~f~ITIOI~~ IOs. tas ~u~opsy 19A. rts. ~tr~ f~nd~nRs tonsidtred • . ~rfenw~d~ .n dr~~r~.,n~ns ca~se o( dc~~A~ Yesl kq(~ 1"es [j tRO ('i a c a or 7ps. Acc~dani Su~ude Hom~c~dt JOb. 1)s~t and Nou~ of In~ury IOc. Ito• In~w~ Ucc~urcd lfwirs wiirri oJ iwfr•r 7'u/ ! n. 11 0/ fu.. l~l ~c~oc~r ~ J ~o ~F~ ~~s~ o/ .rr 4nev/~1R? 7fi~. In~urr Occurr~d IOe. Pla~r ol In~ury ~r R~+ o. ~8nrf Aowt ?!N. C~~r. Torn a I.oca~~on (~nrrur 5~+~~ ~~le ~r i :~or il+~le ( j ~le.~w ~u ~ory ~nr~f. o~/~r~ 61J~ . N~ ! ^ ~ . / ~ ~ork sc ~'ak i ~ ~ ~ ~ f ' A ~o~~ c?.ss. ll. I I~~~ended. e¦am~eed) ~ fdccrastd (lio~n. onl ~o ' ~ed I~st s~~r (Mw. IK~I sl~ve on ' ~ i DiuA o~.~...l.r~Y w oe /Ai Ja~. rritrJ ~bvsi. ~nJ iu ~A~ brs~ o/ wy ~norh/Rr. rM airi~~ s~N~/ ~s 1T,. ~~«~e~~ PA s. ~d. Eaars. ~ou. PA s. ~ • 2~. Address. ~ J •7' 21c. Us~y_S~Rned • i 6 y N1 Y 1_i ~ 7 _ r :~f:~/ ' i . J ~ J • S~Rna~ura?-~ . a,.~-'"~ . l~s. ti~~~al. ( r~au~~oe~. R~wa~sf ' 21b. ( ~~~~~r w(i~+na~nr IJas~ 2te. Locs~~oe ' C~~~/ S~~te ( .../1~ . ~~11"`r`i`^..'7 • ze..e~uwvd em N• • lid 8uns1 Usit Rb. D~f Yr. 1~a Funaral ?{ost Nsn~ 11A. F~nenl Horet Addrt~s . ~an. I/, 1974 /?o ~ C. N Fwc~L Nvm ,39 Svu~/r. S#., l??andoquan, N. _ Nc ial I~r~ ` Rna~ut h . L~cense No. )Sa. Repa~rar 1 ~na Pers~~ - S~R nYte 1Sb. (~ait Rtc'd. b~ Loc~l ~5 ~'A(~'1 01974 - _ , - F':j PAf,E _ - 7 ` ~ , t - _ . _ ~ . ~ _ ~ ~