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. Nth ltlMY iTATt NPYTItM1T M NtALTN
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1. NA1tE OF ffcratl f Mtalffr/ L•atl Ses UATE OF nEATN
DECEASED
rr,~...h+.r, JO_L`1 ~J31'r,) ~rtos ,~;dle ~7, 1971
twit w Rocs S, AAe fra >ra- M arwdet 1 Yr M rwdar 2{ Ika. b. Date al Ewrk 7. ~N Aecea.ed e.et iw U.S. Ar~eat FereN)
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^a aca~ lan i~ : u > 1 Jl ::o '
L Duatyaacs flaeee r /vwyw corstry! 9. Ciliter a/ ta?at p~~l 10. Ilarrtad ~ Never RI•rried p 11. Swcral Secwur w.
Pert : A:::lo7, . .:a.+.i. Pid•~eri(~ Oi..eredt.] i-i?-Uj-i''~~+U A
2. PEALS tIF DFATM I!. U511AL RESDENCE (M iaacutrtiaw: tesidewct ke/an adriaaiaw) '
•.Carawq .lrZ - ..St«. J ?.lo„at, ii•- ~1•:rr'JX
City (Lkeck kea awd Awe w•~t) e. CirY Cl (deck Ma •ud arse w+~e1
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T a' 31't.? is 3G • T
c. sac + yw .r aaattartrer pee strew s. Strew Atlit*. tl/ tetra!. P.O. Address)
~wt~...~ ~ ter:... ?:1 .i7. ~@.1 :~73"~r lOJ Coolie: nv-x:1:13 ~
? Qcnrrwri.w <rr te/ eer /owe jarrtA gaat t . evrw r/ rrtr 1{. sl tkcaawru w kadwny
a inter- ;3 tir~:~ :',o~c ~ cord t iot.
1 f. atkar s were i6. ki•rker'a klaiNa Natal
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7. f.l.rrawu's Natae sad Atkkea•
ire. :a~ic: 3^: Lo (yi:a) 1~0 bolic' ~ :,vLt:•.:~, Ca:-~~i•:t, „~~1a
tA. PART 1 OEATN PAS CAUSED sY Es/ae aw/jr eae carte pr /tae jar lal, (kl atie/ fc) Apptoaiaaaee iwtwtal Marts ~
w sad deaak
kr~e~iaaa G~ecs ta! ~
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h rf craws /pt Orr a fcl
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PART L OTMEtI SIGNIEKANT fpeDIT10N5 IAa. Py asapy 19?. U yea, were tiwdNAs etraidereA e
t.. L .i. ~ _ ~ /{Uw,~. _ '"~'~1 M~ ~ iw ieeetsiwieA caaut al kar?~
_ ,'•M~Ci f~+~~i+~•• Wflfl eMk Yea w p Yea w
?Oa. Accident Sticit#t lleartide 20?. pate awd elate tf bw~ 20c. liar beery Ocnstad (Farr Mere n,rr it P.tt I r 11 y /rrw /fl.
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Pile •t (j 11ca Plikr r] Iw. lertry- at<wt. o//itr i/1j . elr. / ~
~'s>i w Prek ~ ,
c r rtr eaawrd! dre decease! /hat. ar) h sad Iwar w (k~uy kn! di•e ew
Dcra orr rrrl M . a+r eke lafr repel .sate; was/ N tav lrrt .r> Aat+arlrJAr. /?on tie t.rtel aNtef.
i 2a. ArseediaA Pkr. .Far. eewP Pkya. p 21?. Addrraa ~ ~ . ~ :2c. n e tiR
2la. 8waal. Cat~aeiata~ •al 21R Cteaeterr w GtoacerE Name 23c. t.acrw Ciq Sete
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2 fd. Aeiraal Dace IIa_ Da, Yr. Zfa. Fawet•1 Naw iinre 2dA. Frwetal liawe Adana
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'
~ ~ ~ Date 7 S
a M1.~ITY OF PEIitH AMt3UY of Issue ~Zf 7~
PER. ~i' AMtsUY, NEW JEt3SEY USltti
E
~ ' , ~ L~EP`ARTMENT OF HEALTH
i ,,f
" ~TVISIUN OF VITAL STATISTICS
' k•PI ~Y ~q'HA'f '1'fi~:, A~VE 1:: A TltUh c:UYY OF A ttl:(:OHU E1 Lla) IN THIS ll ' A1tTtila+T.
1~_ ~ _ Hershey r MuryEl l~n K.<hl~t
y v1TAL ~'PATISTICS ~Ll-U'a ~ .c~;lb'TkAlt Ut YITAL ST:+T;15T:'~S '
~ %t lan offiCi:._ ct. unl:•e~. ' e:~ tai ~ se~Al of thr Partts Aaaboy
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