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HomeMy WebLinkAbout0967 - - . . . . y' ~ ~ ~ ~°~~32 ~?"s~'~~. NEW JERSEY STATE DEPARTMENT OR HEALTH . ~ •,~r e~ ~`P~'~~~ ~ ~ TRENTON, N. J. '~~600 ' ~ ~ . ' ~ . , .r ' ~ • AVGUS'•_" 2 19? 2 ~ O@' ~ ' _ . . . , ~ .z: _ . . . '\i' .}Y " . . TH1S ~~i ~O QERT~PY THAT THE FOLLOWING IS A TRtlE COPY OF A RECORD FILED IN TNIS DEPARTMENT " oH~ .t~.~ ! ! St~te Regrs~.ar o( Viro! Statistics State Commissioner o~ Health ; { WARNiNG: DO NOT ACCEPT THlS COPY UNLESS THE RAISED SEAL OF THE ~ STAZE DEPARTMENT OF HEALTH IS AFFIXED HEREON. ~szaa : NEM Jf45EY STATE DECARTMEM~ Of NEAITM ~ocw~ swEwu~wee tERTIFICATE OF CEATH S~ATE fllE NUw~tA so~ces 1• N1ME OF /F..stl (M:lt/~) ft.srl - Z. Sea DATE OF OEATH ee~_ow ~on DEfEASED '~l T,~ (~p ) } ~7 Siw-EUSE (T~Feo.PnwU ~..r'..:~21JJ1J ? SC[1i101ii 1'ia18 1`ia 1 19/~ oH~v v~~CE 1. Color o+ Rxe S. Aat 1~+Y~s. If under 1 Yr It w+def 2~ H~s. 6. Da~e d Bu~A 7_ •as dcteased e~er in U.S. Ar~ed ~oreea~ Iys t ntb/~/ Mo~r s D~ra No~.i Me~. ~DY•? 1 10 1(~'l fYea. wo w oa~wow) fl/ rrs. ~i+ w? w/~~~s rerv.l .-•a:2 'U~ f ~ ES 11 8. Buthplace fSatr o? /omp corerryl 9. Cieizto o( rhu coun~ry? 10. Ularritd LX; Ne~e~ lluried t 1_ Socu! Secwitr No. i 3't C? tC?I .:i. rt . iidortd Di.«ced ~ 1~iti_')!)-~ 1~~ ~ ~es~n«.ce !2. PL~CE OF DFATH ~3. USUAL RESIDENCE (1( iase~tw~on: tes:deace bcfote sd~issio~) c~r 'r:untsrdoa- 4~< <~I .J ~ S. Cowxr i~'ercer b. Ciry (C6eck bo: and Ri~e oawe) c. City • (Check boa and ~ire na~) Poro ~ ~~t: ~ ; T. .i l ~T'? ri!.:. ~•OT2 ~ c. t~ia of (1 noe m sp~tal or instKUC~on a~~e screet a ess) d. S~rte~ Add~ess (I( rval. P.O. Addres:) ~ r: ~~o:p~~i i~? l,'e~ :•~n~ it~i ~ , Insucut~o~untsrdon !"z9 ~ ° ~ l:. a. Usual Occupat~on G~r~ 4u/ o/ rw4 do.. Jr~.na most o/ vo:4ua !r/t. rv~~ i~ rerurJl 1~. Kird of Hus~ness or lnd~stry j ~~3:~~~_ ~.A:~3S`C'T' ~_T'S: ~t~i.10:7~3~ Ci~;J ??~'-~C Oi 1,`~t • ~ 1S. Faihn's \ase IG. lAwher's 4aidm Nase i : .1 ~ _ r~. :;~~r~? ;h T.cre :ta "^lar t7. Into:~ane's :~ase and Ad6ess ~ ' j _ : . - :~[i°i~: T.• =i~(t?'OtS: Lil) ~iF:?"C.~:t'2~ ['_C~. ~="-n~:. =~sn, ...v. t ; ~ auSE ?3. P.1P.T 1 nEATH O~5 C6GJEP BY En•t. ooly ont corst p~. be~ f.v !al, Ib1 aR~I (C) A~[OLrJ]t! IO(K~~I Et[r0l11 ' ~ ~ . onsec and dea~A i i ~ , Immed~au Guse • ~ ~ - Cowluaows. iJ ~ry. aEi~b 1~,~) G_"4 ~ • , ~ ao~e nse to ~6o~e csrs~ ~e to fb) ; t •7er•. sr•rewa ebe w~1..- . c~~. ~ iyr~; rarsr l~st p~e to (t/ i ; ra d~~M ..I~~~ I PART 11 OTHER SIGAStFICA`JT CQ[jDITI ~Jr~ I~a. tas autopsr l~A. It yes. tere findinas considned i MJw p«(~rned~ in d:ctts~nsna eaust oi dtath~ I ~ 1'es{-j \o Yes No ~ - E ' oE~ r ?0~. Acc~dent Suicide Iloen~e~de . D~ee and Hour ot [n~ury 20c_ Hov In~~rp cetced (Entrr nstu.~ oJ i+Ir~r in Fnf I o~ 1l oJ ft~w !dl ~ ! ~ ~ n ~ i t1~. brst o/ wy ln~.ltd • N- _ ~ ; ..x'.. In~u:y Occured 20e. Place of Inje:rr a ~n o. ebo~! lwwe. 2(If. Ci[r. Torn or Locatioe Co~:nry S[aee ~ ':Tulc ac ~ J KM fhile ~arn. /artory. st~rrf. o~/~ae b/da.. rtr.) - j ~ Zor1c ~t Sork ~ ! -~s; ~~+ss. 4 ' to ii,,:iV 1 ar.J last sa. (him. kw1 alive oo ~ 21. ( fat~cnd-.1. es+s~~hr dc ~ased tinan. nn1_.~:^ 7~ - ti 1'i f f~; v:F ~..~d a[ n~.n ~br /a~. s~~t Mrr,-.:~d ~o tbe besr o~ mr 4non-1~J~r. 1b~ taucic s~arrd ~ ~ ~~su5 ~~,-~..~n P!~ ' yrl- +n.'-' Co P. s.' lb. Addresc l 2c. Uaee S6 ned 3 r.:• ~ ` ~ y.'~ > ` ii.znt~rdon i•=sdical ' / ~ ~ ~ _ ~ i/~v 'r ~ ~ir~n~c:ue ' (~t,t,.(.tis~ n n n {r ' : T ! + - - ~ „ ~ 21a. N~n~l. Crecur~o . Rrmnval 13b. Cenreery ~rA~r mi• Naae 1ic. Lucai;on C:~y 5[~ee ` ISF.../y~ .r,?} • • _1~ - it• :i~,-• c.~' ~ 3t~ a r=~. 9~ria1 Or.~ ••c. Uay 1r. ?4a. Fener+l H••:re Kar:r :~y. F~~era1 Flome A.~ress e ~ ~ . " . t'. :j'7~~ ~ ~ 'T-.- II'jr• ~ ~ ~ . ~ 1'~.'i .7t. .'i:yi'J'~~ •..c: • ~ / ~ ? :4c. t ~:,,er.l [~~rzceor ~~,numC 1. l ~crnc- ~~evar '~~m etni~ - $,~naevre 2;b. Daee Rec'd. by Local _ ~ , s _ y~ :fl j~ r ReR~ccrar ~ z . ! ) ~ i1' " ~J , / pS~.~ ~ , . , . u F~--J- ? ~ r :i . . ,.~f -s ~ , ~ z s 3 Fi~E~ ;,r~~ n~COR~~o7 3 ' ~T ~~~~'Ta~ r~ ~ ' F ~ " . ' ~ ~~oO ~ ~7J ~.r~ Z0 ~;'1 ~1: 4y ~ ~ t . . ~ ~ ~ y ~ 600K J~1~ tACE 9V7 ~ ~ I ~ ~ ~ , t~....~; . e . ~ ~