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STATE OF NEW JERSEY 96
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4 OFFICE OF REGISTRAR OF VITAL STATISTICS
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Tbis is to Csrti/y tLu the following is oocrectli? copied ic~c~ a record of DeatL io ~r office.
NAME OF DECEASED PLACE OF DEATH DATE OF DEATH
ROBERT G. SCHMIDrT , 20 LYNN DRIVB FBBRUARY 17, 1972
SOCIAL SECURITY NUMBER SEX COLOR MARITAL CONDITION DATE OF BIRTH AGE
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- 126-16-3173 MALB WHITE MARRIED FEBRUARY 12~ 1927
PLACE OF BIRTH CAUSE OF DEATH
N&W JERSEY LYMPHOSARCOMA
SUPPLEMENTAL INFORMATION IF DEATH WAS DUE TO EXTERNAL CAUSES
~ ACCIDENT. SUICIDE OR HOMICIDE DATE OF OCCURRENCE
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WHERE DID INJURY OCCURt
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OID INJURY OCCUR IN OR A90UT HOME. ON FARM. IN INDUSTRIAL PLACE. IN PUBLIC PLACET ~
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WHILE AT WORKT MEANS OF INJURY
NAME OF PERSON WHO CERTIFIED CAUSE OF DEATH ADDRESS
` RICHARD L. KLBIN M. D.
! r 200 BNGLB STREET - ENGLEWOODr N.J.
Reg'tstru of Vital Statistics
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Address
Nov~etuber 7, 1979
.........Date of Iswe
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