HomeMy WebLinkAbout2806 450164
P-1492
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STATE OF NEW JERSEY No.
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~ QFFICE OF REGISTRAR OF VITAL STATtSTICS
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Tbis is to Csrttjy tL4t ~6e Eollowina is aoccectlr oopied kom s recocd oE Death in my ofGce.
PLACE OF OEATH DATE OF OEATH .
NAME OF DECEASED
Vau Dyk Haaoa~ N~rsing Home March 2 975
Mari A H o Hoat air N~I AGE
GOLOR MMITAL CONDITION DATE OF BIRTH
SOGlAI. SECURITY NUMBER SEX vrea. wos. ~vs
LSS-24-4628 Wida+ed October 3 1896 78
089-05-5786 D F •Cauc.
CAUSE OF OEATN
PIACE OF BIRTM . •
Newaz~k,N.J. Pneumoaia. org~ism uicletera~ined.
SUPPLEMIENTAL INFORMATiGN IF DEATN M~AS OUE TO EXTEFtNAL CAUSES
DATE OF OGGURRENCE
ACCIOENT. SUICI~E OR NOM~CIOE ,
»cetrr
WHERE OID INJURY OCCURt sT~Tc
c~rr ow rowr . eonrrr
DID INJURY OCCUR IN OR ABOUT HOME~ ON FAftM. IN INDUSTRIAL PLACE~ IN PUBLIC PLACE4 ~~E~~~Y T~~[ 01 ~LAC[
MEANS OF INJURY
WHILE AT WORKt ADDRESS
NAME OF PERSON WMO CERTIFIEO CIWSE OF DEA7N
~c~i ~g~.o 200 Highland Ave . Gl~en RidBe , N. J.
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Reaisau oE Vital Statistic .
}{EALZH BEPARTl~HT,NOiITCLAIR, NEN JERSEY
.
Address
June 21, 1979
U~te oE Issue
~50164
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