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DEPARli•~'i' OF HEALTH AND ENVIRO~ITAL CONTROL
Bureau of Vital Statistics4~~i?2i1
Irvington, New Jersey 07111
This is to certify that this is a true photostatic reproduction of a record filed in
this office.
~ ~ /
~ ~ r
ose .Wright
• - R gistrar
Date of issue ~
F~t.fG wltt b~ELD
DO NOT ~ SCRIPT ~ImTI~SS THE RAISED S[~ sal~l(nr.
SEAL OF T$S ASGIS'TRAR IS AFFInED HEREON. ~r~s -
_ _ - - - - - _ . _ r.~ranc~~T~n 9•
NEM JERSEY STATE DEPARTMENT OF HEALTH
. ~ O LOCAL FILENUMBErt CERTIFICATE OF DEATH STwTE FILE NU•rBEtt
Sr+wCES 1. NA.41E OF IFrrsr) I Mrdd/el ILast) I. Se: S. DATE OF DEATH
eEt.or FOR (CEASED
STATE uSL ~ • ~ _ /
oNt.r ITypr a P..rt) %/Q ii?/ ~C'- `tom rN1~C~ t~ /5/G'-•
PLwCE 1. Col« « Race S. Aar ( ys. 11 untSer 1 Yr 11 under 21 Hrs. G. Date Berth 7. was deceaxd erer in U.S_ Arued Farces?
~ _ last brrtbday) Mowtbs Dwys Norrs Mrs. a IYrs. wo, or rrlnnw/ IIl yes, seer ear u. dales of srrr.l
~ 8. Birthplace ISufr «(ornar corntryl 9. Citizen))oI that country? 10. A;arrieerer Marncd L~ 11. Social 4curiry No.
eUL. ~ X , ~ r s L!, ~ ~ ~ _ 4Sidore J Div«ced [ ~ / ~ ~ ~Q S
II REStoENCE 12. PLACE OF DEA 13. USUAL R__E_~~E~CE If institution: residence bef«e admission)
a. County ~ ' Es a. 4ate/fr/~(s/ L?izje b. Coutwy ~C S
I
b. Crty [ (C ck boss and afire name) c. City (_7 (Check bt~a and atre rune)
B«o[ J B«oL1
I T ALL! /L T. p v .t lG .
j / c. Name of (1l o« in hospital « institution sire street addr s) d. Street Address (I( tars], P.O. Address)
Ho:~ml « • r
s-In tuut;an S I G e L S. a s • ~2 6 r P?-r -S' T
j 11. a. Usual Occapaeion (Geer 4rnd of ror4 dowr dr.rsa Host / ror4rnR rJr, r.es r/ rrhred) l~. b. Kind of Busines « Industry
4 ~
~ c v ~ f- t.z, ! e _
IS. Fachn's Name IG. Mother's Maiden Nara
b ~
1). Inl«m nt•s Name and Address
i
CAUSE 18. PART 1 DEATH iAS CAUSED BY F.etrr os/y one rst per (ewe Ia), Ib/ asd Ic Appro:tmare tntetral brtreen
~J~_ onset and deuh
immediate Caux (ai • • •"'`~~~'"w"`~ ~
Cowdrtrorrs. i/asy, trbrcb ~i~ 't V •L~'1.~~1L
sate rue to above rarse Due to ft:) r
~a~', statrwa for rs/rr- ^ ~y~
Co~buaws caw- rs rarse lest Dar to fc) j`l,r v
r.~?vr.w, N ~aarA
b,.r MI Nla•a~
ro +tir .....bars PART 11 OTHER SIGNIFlCAVT CO[CDITIONS lna. has autopsy 19b. If yes, rere /indinas considered
performed? / in determining cause of deaths
Yes [ ) No [ Yes No
20a. AcC,ent Snde HorCc)ide 20h. Date and Hour oI Injury IOc. Hoe Injury Occurred IE'nrrr sate•r of m/rry rn Port I or 1l of Irrw Id)
l\- to tAr best o/ ny knov/rd r M.
Pcacc or j(Id_ Inlury Occurred 20e. Place o/ Intury /r ~ ra or abort h~•:r. 201. Cic Torn « Location Count
•ctro[wT chile at )tile /ant. /arrory, sfrert. ol(rrr bldg , etc 1 Y. State
Eork at K'«k
g 21. I (attended, sa+~r:wed}~rC..deceasrd ((u+m, en? to ~ - and last sae (biwr, hrr_) ali.e on
$ ~ Oratb oerrnrd oI n os tAr dare stotrd shore, asd tv tAr Irrsf of rwy 1wor~lydRr. /r..w. the tarsrs stated
IIa. Attending Phys. d. Esam~. County Phys. 211+. ~dr~rcfs H / ` j C ~ ~ y V 22c. Uacr Signed
Signature Y, ~ y~T''E'~ /'7 s 1y~5 is U~-) OC;~ v j
c woss et.wss. 2Sa. Burial, - 1 23b. Crmecer M Cremac« Name ar • ~ ~ ~
ISprrr ~ ~ A / Y Y 24c. Location City ate
CENSUS 21d. Burin Date Mo. Da Yr. I1 F real Home Kane I
TRACT Y Ib. Funeral Hare Address
a
/ Funeral Drtr t ~i aty4e, N. Lrcrnsr No. e r ar s r ISb._QiD~ata7et Recd. b Local
w[G. ra ~ r ~ ` V V~ar1 8 1976
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