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NELti Je N~eY 1.ri Aik UkVAiif ik7~1 OF HEAL lee ~ '
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• - CERTIFICATE CF DEATH
'-aCE - - - - - 1. NI1ME OF DECEASED /irtq Qf.Aalt/ ILaW I DATE OF DEATH
~ TIYEY lCct.2 1 ,
_ _ 3a. PIACE OF DEATH (Gry or Town) 3b. Courry 1a. ResKferro {vo. ano 5:.1 b Gry or Town c
Paterson Passaic 20 Pros~e~~ ~
i Sa. Nance of Hospital of lmtiation 111 cwt eiCsr, gee Ho. and 5t 1 - - 4c Caunry - - b. Sate 4e. InsM•Gry lun•[s
St.Joseph Hospital Passaic N.J. ~rn
/ M • 5b. If Hospital or Mstrtutron, cffec! rnrre[t bow fi Writal Stebfa 7a. YWe OewssO tear rs U.S. Miitery 14 Wr 1 7c O+te -
t ~ ~ Cl DOA C7 Inpatwnt ? IWtrwd 3 U llydow.d If "Yn" tnta+ Nx aM ONw From-
~ t ~ Emergtertcy !7 Otftet: _ 1 O S+gM 2 rJ Sp.ragd ? ? Dnorod U res ]Q No ~ To:
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v+TAL - - - ° ~ >t Srw ~ 9. Date o/ EMrtA 10. Age Last B.rtAday I l a. UrCe• "1 ° Yer----- ' Ib. U.~+der "1" Day--
Female M_arc_h___21 1 14 ~ °'~r' -`-`'S
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f _ _ _ _ _ _ 1?a. Brrtttpla,e. lSiatt p Fpe7n Cpnery) 1?b G[.teo of wfut Gaint.y T13'SwrrrKeq Sooute 11f tit+r. `.Lien r:amel ' i Soaaf S.or•tr Vuwwt !
` `clarion Ohio ~ m
USA ~ 1 hor?~s A~,b e~._._iv_e~-L 1 ~?-10-6072 i
115, Raoa lfi EtMie Orrg.n - _ - - n Ya^.» +ruf A,:Geu o lxt kmpM+yer
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_ _ _ _ _ - ~ eta~t o cam. cer~ - i1~Y1e
3: a TferyJ?CE ~ 18. usual Oocuwaon IKu+d of work done most o1 19. Kind of Busutess a Industry ~ 1
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~eousewife _None _ _ _ _ _ _
~iE M' ?ll. NAME OF FATHER IFrq IMrddMl ILxq ?1. MA1DkH t1AME OF tt0*NFR (F•rsth tY.•ddfe) ---llastf
~ Tedeski I
_ _ _ _ _ _ ~ Peter _ Vi~ins _ ! Pauline
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,:!wIC ~ ?la. Name of Informant f ?tb. RtytwndW ?ic. Nurntfet and S'ree[ ~ ?id. Gry at (own- _ ?le. Sate ,
~ Clifton ~ N.J.
Thomas A. Tive_~____ ~ Husba2l,~_ 20 y~_rQ~n~..~~ . _
~ rauSE - _ _ _ ??a. Dispositron rJ p.n,~y ??b. Name of Cemetery Or Gematory ' 2?c. C.ty or Town r ?Zd. S:ar
burial ~ Ottrer:
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j _ at`- Of - - - r_ i 23a Name and /IOMess n1 Fune.at Fsome ~ ' . 5'yr'a~/e of c,,nav~..er~r` I+ 7~3t H.J. L.cense `/o.-'
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