HomeMy WebLinkAbout0413 •
.
4'7~i~72
I ~ C tTY Ot= NEWARK, N..l. Nu 12402
OFFICE OF
AARON H. HASK I N, M. D_, M.P.H.
- Registrar, 8ureou Of Vital Statistics
This is to Crrtify that thr folloaving is corrrctly copird from a rrcord o/ drath in my officr.
DO NOT ACCEPT THIS CERTIFICATE UNLESS THE RAISEO SEAL OF THIS BUREAU IS AFFIXED HEREON-
NAME OF DEG[AIED M FLACE OF DEATN DATE OF DEATN
sOC1AL lECURITY NUMlER !EX COLOR i MARITAL CONDRNk! DATE OF IIRTN AGE
!LACE OF lIRTN I CAUlE OF DEATN 4 ~ ~ I
p~ «i. Z~ttintsl L~slraloLi+m.
~ Bart~ipo+ly
i
SUPKEMENTAL INFORtiAT10N IF DEATN W/1! DUE TO EXTERNAL GUlEf S
ACCIDENT. lUICID[ OR HOMICIDE DATE OF OCCilRENGE
lr~ctrr
WHERE DID INJURY OCCURT -
cmr ae •oww ooUrrrr srwn
DID INJURY OCCUR IN 011 AIOUT NON[. ON FARM. IN 1NDUlT111AL PLACE. IN PUIiJC PLACET
iltCtFf •ff[ OI ~LACt
WHILE AT WORKT BEAN! OF INJURY
NANE OF PERlON WNO CERTIFIED CAUlE OF D[ATN ~ ADDREp
C, Y. BSd, K.D. Nwtels~k eatb Iasral Ho~p~.ttl, ~rkf 11. J.
In Wilntsr W~ier~oj, I have hueunto set my hand and affized the seal of Bureau of
Vital Statistics, Newark, N. J., this.......~.........daq of........A.D. 19........
4'89'72 ~
~ ~atc i i ~ ~i: az ~
Re=is<rar of Vital Statistics
- i
t~ vEJttFIEd
4
yy~~ ISM 1-72 24 Safetp Paoey ~ l:
f~C