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d~''~'~r STATE OF NEW .1ERSEY
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OFFICE OF REGISTRAR OF ~/ITAL STATISTICS
~ ~ Lakewood, Ocean Count
of
- ~ CITY. MROYON OA TOWN~NI~ ANO OOYNTY
T'bir it ro cntif
y that the following is correctly copied from a record of Death in my ofllce.
NAME OF DECEASED PLACE OF DEATH DATE OF DEATH
h~istace Alsop Paul Kimball Hospital Jul 23 1 1
SOCIAL SECURITY NUMBER SEX COLOR MARITAL CONDITION DATE OF 61RTM AGE
YRS. MOS. DAY
083-3b-1884 Male idhite Harried Aril 16 1902 6
PLACE OF BIRTH CAUSE OF DEATH
V a. ~ Cerebral Thrombosis .
SUPPLEMENTAL INFORMATION IF DEATH WAS OUE TO.EXTERNAL CAUSES
ACCIDENT. SUICIDE OR HOMICIDE GATE OF OCCURRENCE
SPECIFY
WHERE OID INJURY OCCURf
CITY OR TOYYN COUNTY STATE
DID INJURY OCCUR IN OR ABOUT. HOME. ON FARM. IN INDUSTRIAL PLACE, IN PUBLIC PLACEf
f~ SPECIFY TYPE OF PLACE
WHILE AT rIlORK7 MEANS OF INJURY
NAME OF PERSON WHO CERTIFIED CAUSE OF DEATH ADDRESS
Irwin Roseff, M. D. LakeWOOd, N.J.
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I
Registrar Vita
j tics
351 Ridge Ave . , T~akei+FOOd, N. J .
Address
Feb. 18,- 1972 `
Date of Issue
B.H. SOIN
of HLR rUiLifNlNa CO., INC., TR[NTON, N. J.
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