HomeMy WebLinkAbout1311 ~ t
i
rs8o ~R i s P~ ~r ~ i
ftLEQ A N~EG~Gi1Gk0
s 1tE0~~Eit~POITRA
S ~ -
Ol~1tli CdtCUtT COURT
483'086 ~ 0 i
MONTCLAIR HEALTH DEPARTt•~NT
MONTCLAIR, NEW JERSEY ,.1 - _
Under my hand and Department Seal I certify that this is a trut photostatic
reproduct#on from an image of the original record.
fEB 5 980 Registrar of Vital Statistics
DO NOT ACCEPT THIS TRANSCRIPT UNLESS THE RAISED SEAL OF THE TOWN HEALTH
DEPARTMENT IS AFFIXED HEREON.
NEW JERSEY STATE DEPARTMENT OF HEALTH
_ _ _ _ CERTIFICATE OF DEATH
~ v~wCE 1. NAME OF DECEASED fF%st/ li/~d~e/ fLaeU 2. DATE OF DEATH
~ 3 -
_ _ _ _ _ 3E. PLACE OF OEA Gty of Town) 30. Cana 4a ReydEnq . sM ~ p Tom
NES~DENCE ~ .
d~
Sa Name of ul a Insti pt rot eitlrer, y~ No. end ~ k ty ~d. Stale 4a prside Cily Limit
° ~ e~_ _ O Yes O Mo
w 50. It Hospital a Inrtrtut c>tatk ruts 00: Q MariW Sups 7a We Oepard ew it U.S. Md' 70. Wx 7c. par-
O DOA O Inptiwsl 2 O Mrrid 3 O W If `Yet' unto War end Oetea Frbrp:
1 _ _ _ _ _ _ w O Emer~eocy OMer 1 2 O Sepretrd ~ O DiwroW O Yes To:
ras?iTAL ° a Sn 9. u of tlirtA 10. Aye Let BrthdM 1 to under ^1' Yw 110. Under'1' Day
- - - - - - ~ r YONTNS DAMS MOUIIS YrNYTES
1?a Birthplace (State a ay 120. Citizen of whit Country 13 SsrrTieiny Spouse IH tAfAe, Maiden Name) 11. Sayet SearitY Number
i 4GE
i
j 1 Rao O M~~ 16. Ethic Oriyn O ~i~ OIAer (SpeSjty) 17. Name and Address of Last Empbyer i
i - e 1
O OtMr ISoecih) O Puerb Rion ? Italian ~
Buck O Cubrs O German
~P ~ R TM1.IICE o ~ la. IlsuM OwrOttiOn (Kind o1 work done most of 19. Kind of Btrtinete a
~ _ it retired) _ i
1~ i R"CE - - - 20. NAME OF FATH (First (Mdd4) (Lull 21. MAIDEN NAME MOTHER (first) Widd4) ~ILtW
- ~i
THNIC ~ 21a Herne of Intorrrstnt• 210. t 21t Number Su 21d.
• - - - - - - _ ' ~ 1
GwVSE 22a. D' O Removal 220. of a G 22a City T 22d Sute
sal O OUw:
~ _ - - _ - - D Gemation ~ i
i ?ucE Oe ~ 23a Nsme srd 230. a of el Director 23c NJ. L ,
i wcc~DEar ~ FUNERAL H0111E_ I p e i
° 76 PARK STREET a 2.n Date r~/w
rcROSStuss- - - , Q O t
~IONTCLAIR N, J. 07042
1 25a w.r .ee "ee... M C.ui.- wnw.r e'eea O Mud E:aR O 250. Te rr e.n e, r,s twewrse,.. A.erts w s..a.w. pw+e, M a w.w aw.d
~ 3 O ~ ~ C ~
1~'- O ~ f2,.~ T' 25c Date silrred 26a Hour of PrdnoKrod D.ad
i ~ c ~ n~ P - ~ . --z 7°3'~ DATE/, ~
_ _ _ _ - _ - 27a PART 1 1 .ate Cause - (Four only oneuouse pr line tOI Ia), lbl. - kl• IrAeriral bttsrews and dewp
a L -l. ~ ~-L- 1.i 1..c Fig ~ vt' ~-[~~.u~ _
Duebaea
t ~ Due to a e a of .
° f
~ c
° PART II OMn si¢silit.ant oondnions - oonditiom tantributirp b desM but rot re4ted b Huse in PART 1 We Avbpy 20. We ou rtterred b MMi01
w
prior ar Cororw7
O Ve Ye O No
30. Desth due b O Homitade 31a Desonbe pow Injury ooturad 310. Dau t
Injury 31C Nourd Injury
O Accident O Urdw Irnestyation
~ O Suicide O Other -
REG rB 31d. MNy a Work 31e. Poo a Injury O ONsoe wriEdiw/ 31f. Colston pio. and Sal 31y. City err Two 31R Sate
n O Ye O No O Home O Street O Otlrr
- _ _ _ _ O Farm O Facsory
6~~329 PGGE1J~a