HomeMy WebLinkAbout1604 1
449 HEr IERSEY STAT{t OEpRRTM[NT Of MEAITN ~
a CERTIFICATE OF DEATH a~.rc rr~c wurtr:~ ~:f~~ s
f.oC.? r ct! wurt.E n ~ /
so•c[s 1. NAMF Ot IFusU I M.J/IrJ Hurl 2. Sta 3. PATE OF OE ATM
.coo. row DECEASED 1
a,•,r use IT,Fr a p.r.r, ~N~REM Q. M~Dl3 bale Jane ~ 1975
v~ •C[ Cola a R.ct 7. ARe 1.. ,•a 11 .rider 1 Yr 11 .rdn II Has. 6. Dre d BucA 7. 1.. dtctawd tvtc iw U.S. Arwtd F.rct.'
l.ar l•.N/~)1 Mo.c s D.)a Hoaq . N~.. l1'ra..o. d a•.l.oc.~? If/ era. jnv a..• w Lua Vl am 1
Caucasia~a , r. LO 193A No
g. NurApl.ct Ilene w /orr.R. •urnr•)1 9. (iti:en of rAaa counu,' 10. Marntd~; Ntvtc Narntd[__/ 11- Soc.al 4cuntpp, No.
(}reeve II S A i.dered Dnaced . 09 ~7VJ9
k t•.ec 12 PLA(f OF DkATH If. USUAL RESIDENCE (11 maucexwn. rta.deact l,elort .dwisa.en)
e.,rnr, BB !E! ~~e Aex Jerae~ s. e..~, Bergen
A. (-rc, . ! fCAeck Ao. and R.vt name) c. Cu, 1 ICAtck bra and stet nave)
1?.ro( ) ~ Tr
paraa~ua
T
c. Nawr o 1 na m Aoapual a .nacuw.or. grve screen eaa d. Sueea Addrt.. (11 rvd, P.O. Addrea.)
Hoapral a Vall Ao ital 7b9 Par+alwls lzOtd
• Inac.taron
11. a_ Usual Occrpar.oA /bra+ !u/ o/ ro•! /.wr /v..+d soar o/ rerlr.j b/e. rue. a/ rrhrt/l 11• S. Kiwd of Msiwtaa er Mduatr,
Omer of rsataurant roan Diner
I)_ FarAer'a Nawt 16. lbcAer'. Naiden Nave
Q~1(.gs Oraa Haneaais
1'. Ido.>•.m'a N.we and Addreaa
lCatheri.ne Kandaa~ Paraania, Aew JeraeT .
c •us[ Ig_ pART 1 DEATH iAS CAl`SFD BY E.ltr o.l, at «wr Fee fur /a L). Il) ..I lr) AFpreaiwwe urervO becreen ~
~f~ owsec .red dtac
~ 1
Iwwed..re Cause L1
Co./uro.s. r/ .w,. rl.cl ~t~ia-~ ~ ~ ;
env net ro.lo.rt c.wr Due co /l?
'7.P'. sr.trwj for plrr- .
III I,r.j [.wr r.a?
Due role/
~..•.-r a.r. ,
" "~'•ie PART 11 OTHER SIGNIFI( A.YT (Ot~DIT10N~ ha. ~.s swops, 1•JE. II ,ea. rtn 6ndmp considered
~rr.a.• perfoewrd' i. dettewin.ng cause of de.rA' •
I ~,p,....J ~ f~/^^" Yts ~ ~ Pio [_j~ Yes ~ fro '
~ a or IOa. Accident Swude side IOC. Dane said Hour of Intvry IOc. ~ Iniv) Occurred /F.rrr uar.r o/ •wrrry .w p..r 1 n ll o/ Ib•i !Rl r
~ to aAr bsr o/ wy lnarbl r M.
20d. Incur, Occurred 20e. Plxe of In~ir, Ir t rw o..bar bar. Ip. Cn,. Torn a Locauon C oenry Sr art
tA.lt a• ; Nor ilydr f h•~ l.. ro.) acrrrt o/l.cr I/Jj " rrc )
fork .r yak
•o,t c~•ss. 21. I l.aendtd, taa.iiadl rht deceased Uraw, onl ~ •17+~ ce and last sae IMw. Aer) al.vt on •
i Or.rb ocrr.•r/.r o. ?br /ue ararl.bor...I ro clt lest o/ a, l.or/r /.n. b c.aars stare/
TS 2Ia. Arctndina PA,a.: rd. Fsaw j- ~ Cowr, PA,s. } I7b. Addatss 2It. Dart SiRntd
J~j PROfES510NA1 /13~OCIATION
Signature ~ I~ v ~ 11 .26 SADOLt RIVdt ROJ.D
2Ia. Bwid. Creraaci t.wva 2)s. Crr.ettr, p Crtwaaa, N.we FAIR NnelprQlllD Cu, Sract
ISFrc./yl
Burial Valleau Coasts Ri enrood l~s>~ JerssT 1
IW. Burul Drat Mo. Da) Tr. IIa. Funer.l Hover Nast Ids. Funerd Howl Addrts
Jmss 18, 1975 Vander Plat CoLoanial Aor fair L~n~ l(sv Jersey
2k Funer.l Dirrccm a N. J. L ae No. eg.saru (asymg Peewit - SiFw.cure I7s. Date Rtt'd. .I ~
Rtpvnr `~(s
~7
.t~,~a.:
r
THIS IS TO CERTIFY THAT THIS CERTIFICATE IS AN EXACT COPY OF THE
ORIGINAL FILED IN THIS OFFICE.
~ ~ ~ 1
DATE : G ~-1 I I . I ~7~ " ~
h
464549
3(9 NoV. 1 1~ i
~ ST. LUCIE CCUN1 Y. F 1 A
ROGER PGiiRaS
CIEAit CIRCUIT COJ~
e~-r-.~ ~:r~i•~ 9" BDJK~~e7 PAGE~~~7 ~