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HomeMy WebLinkAbout1194 ~ J . , i ~ i \ . : . ~ . . ~ : ~ ~ ~ Q( - _ - - - : - ' - ~ R~tW. ~ ~ - ~ _ : y ~ ~ t ~~1?n9~ Y ~~y ~n UfF ~ } ~ _ ~ ..Le~,~„IaY' ° ~ ~nsa~+~ . . REC . ~ ~ - : 3 . ~ ~0;: . u~~'e'raY~eiY~ I~EW .IERSEY _ ~o.` , i; 5'~'ATE OF ~ Y t ~~ive ~P . . w~p c _ , . : : : . : ; ; ; . ; ' ; , . , - a R ~ v~~?FFICE OF REGIS`rRAR OF VITAL.. ~TA'T(ST1CS ~ - ~ - ~ , ~ : - ~ - ~r ~ ~ oE :.4~' ~~!l...~~ ~ ' ` . . ~ city. HosouaR cr ro~isAip aad Coancy _ , : x] ` _ . . _ _ - _ 1 ~ ` - 4 . _ _ . - ~ _ - _ t. - _ _ ~'!'bis'is to Certi/~ t~at t~e folioivi~g is correctly o~pitd fro~n a recocd of Deat~ in ~ioy ~office. ° ~ . _ _ . ~ _ - : _ - - NA}AE OF DECEASED • _ ~ - PU1CE OF DEA7H ' ~ - _ DATE OF DEATH: ; ; ; ; , L _ - ~ - - - _ , . . . , . - . ` _ _ 3 [f ; 50CIAt. SEGUR(TY.MUMBER -''SEX.: ~ : ' COLOR - _ _ ~MARITAL`COJiDITIal1 ~ DAT~ OF BIRTH - AGE : - , - - : > z ' _ _ : ~ ~ _ _ ras Mos wvs - PLAC~ OF SIRTH ' ~ . - - CAL'$E OF OEATH - ~ . - - - _ _ ~ ~ ,aQ~ - ~ ; ~ ~ ` - - SUPPLEMENTAL INFORMATION IF DEATlt WAS ~UE Td EXTERNAL CAUSE571w ''rl ! : _ _ _ _ _ ~ . - , ~ _ - _ : . AGCIOEItT~ SUIClDE OR ifOMICIGE - _ . : : + , ~ = ' ~ , ° DA7'E OF OCCURRENCE = N ` ~ ' ~ ~ ; ~.=;s ' u~e~sr _ ` - - s:: 3. ' WMERE DI~D lMJ1AtY Oi:CURt . - . - . - , - _ r~x . j~ t. ~ - . erTr or Yow~ = = eowrrY . ; at~T~-'~ ° ~ _ ~ . D!D lNJIMtY, OCCUR `i1i QR ABOUT NOME. ON FARM, IM lNOiJSYRU6 PLJ1CEs IN '.~UBLiC PLACET :=.~+c., ~V• ~ : , . - - - : = : s~e~ str?c c ' WHILE A7 WCRKT • - - - ME/1NS ~OF IiUtlRY t ~ - 3' . = r~~ ' ~ _ ~ - - NAME;O~:PERSOM ~IHO CERTIFIED CAtiS~.OF'OBJITN " - ° - 'AOOR _ ' ~ z~_ • ~ { ; - - - - - - j _ _ ~ ~~j ~ _ - ~ ~rt s _ ~ ' - ' - _ .:I~ICiE _ - ~ : _ ~ = R~ it r - j - ~ _ f~ ~ , ~ ~ ~ECeRc 1~~~~~ ~ F F :4. } = - - 3 F r l _ H ~ N~iHM~ ?~w~~ w~w~ . ' S" ~ . , ~ ' ~ ~'~jr R :ux ef vlsa! sasl:cic: - : ~ ~ ~ ~ f,a - - - ~ _ 1~it~ ~ - . . , . , ~ ; ~ ~ - - _ ~ _ _ , _ Addres~t ~ - ~ f . . ~l~~ F . _ _ . ~ t ~ - c~~ _ - ~~.1 ~ ~ { i!1 i •iNe ~N~C . ~~~~U . _ ~ ~ ~ _s "'~='~z~ ,~r1: i~P~e O~ is~1Q~ ° - - - - , ~s , . t ~ - ~ ° ~ ; ' '~Y'.~4 ~ 2 ~..~..~t .~.~rf.~' % . r~ : R~I~ fa z r A~.. " . O a ~ ~~~f~ , ' . ; ' ~;~tJ.z ~~~i~~R[NTM1~M ~ , ~~~i~ ~ _ _ • - ~ y 'i~t-.:`a. :-t~r ....y.~~:s'~F ~;Fr~ iz s..~ _ . . - _ . ~t.`, .~:1~t.~ .e.a~5~r.?F~~