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' TQWNSH~" OF [~OV~R DEPARTMENI' UF HEAL7N
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DATE: '
~ This is to certifv that the followin~ is a true c of a, record filed yn t~is dep ~~en~.
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, Reyistr~r of Vitsl Stat~st~tt ~
~V A K N I N G! 1)O NOT ACCFFT T}i1S COPY t1N1,F.SS THE RAISED SE
~ O!~' THE IIEt'AltTbiENT OF HEALTH IS AFFIXEI) ~IERF.ON.
kEW JfASEY STATE DEPARIMENT OF HEAITN
CERTIFICATE OF DEATH
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+ie ~1. NAME OF DECEASFD fi~rrU lMidaYel ILuU 2 OATE Of OEATH
~ Robert R. Plosica Au . 12 I98 '
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_i i Ja. PLACE OF pFATH (C~~y w Townl Counry 4a ResKlmce ~No. srd St.1 tb. C~rr ~x ion*+
<,pENCE
DOVER TOWNSHIP oc~ 200 Pershing Blvd Lavallette
Sa- Ns~ne ol NosD~tal or Institutbn pt not eitfxr. yne Mo. ~nd St.l ~c Counry {d S~ate {e. I~n CoAe----- 4f Imdr C~t~r lmih
Communit Memorial Hos~ital _ Ocean NJ 08735 x Y~, ~
N~,~5A. tf Hospts! d Instit on. dkclc oorrM bac fi Mxitsl Sutus 7a. Wn Dejeued e~ n U.S Mditr~ 7b. Wa. - 7c. Date
W C; DOA npiumt ? 0(Mxr~ed 3 Q Wdowed if "Y~s" enter Ny s~d Mttt ~.Tt.T T T from ~ -
• .~i C] E~*wqency ~ Other: 1 C) S+nyFe ? C7 Srparste.l ? D Dnorad Yes L] µp ~t A 11 To: ^
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.-~;~riT~~ 8. Se: 9. Date of Birth 10. Age lxt Birttd~y tlt lhnfe+ •.1.• Yex Ilb thider 1' Day- -
Male Apr. 4, 192?_-- - - 56 _ 4oN:MS = { o„~~ ; ~~,,ps _1 ..,..~,ES=
- ~s. B~rtbplace ISute or foreiqn Cnuntry) 1?b. Crtirm of wAat Country 13 Siuv~rmq Spouse (11 Wde, M~idto Nsmel ~ U. Snc~al Sec.~~~y Mun.ber
j Alice A. Salkauskas 150-14-4492
New Jerse U.S.
~ ~15. Rsre 1& EMmcOrgm------ -L--- 17.Name~ndAddreoolL.sltEn+Pbyer .
? a„e.~can ~~a„~ c a µer~a~ ? ome+ ~soec~N)
~Cthh~te Other (SOecify) CJ ~txrto A~un !J IbGm ~
~ ~l Black ? Cuban Gnm~n -
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~~~uce o~ IB ~ISWI nCCUM1Mn IK~nd of wwk done most oi T9. K~~d ot Bus~neu or Irdusiry
~ L~le even 11 rebr
Owner - ~erator Motel
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,~?0. NA1NE OF FATHER Ifnst (MddM) (latt~ 11. MAIDEN NAME OF MOTNER (Fuitl (M~d;t:.~ Ila+~l
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Michael W. Plosica Stephanie Gruszkos
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'~v~c ~ 21a Name ol Info.mant 21D. RelatansA~ -?lc. N~m6er snd Svee: '~OO ?lA. Gtv M To.m- - ~ T 21e. State
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Z<, Alice A. Plosica Wife Pershing Blvd. Lavallette ~ NJ
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~ _ se - - - - _ ?2a. D~spos~tbn RM~~ Z2b. Nsme of Cemetery o. Gematay ~ - ~ ~ 7~c Gry o. Town - 72d. SUte ~
Z`~ ° o«~ Holy Cross Cemetery No~ ~ NJ ~
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Of ~ ?3a Na-ne sM Address ol Funeral H~me ?3b. $~q+aturc of F~wrcr~l p~reetor 13e N J. l~anse No.
1CC~DFNT ~ q~derson & Campbell ~
?03 Main Street ~t~ ~ _ _ . _s 6 z~ ~
_ _ ~ e of Regist~x ~ 2lb. Dete ~ecerved by ~
>ss~~~ ~ Toms River, NJ _~,s,~_~'3 ,
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25i. Ns~r ud ACd~~ af ~.r,Ie.- A~bM~^i PhY~ C J Wd. E.am ~§O. To ~M Ert ol ~d H~ (sc~e fyvlfl s.~~wf. '
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j 1 ~ 25c. ate $qrxd - ?6a. Ikwr ol 2 . Rmountnl Uexf
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u t ~ ~(Q~1l7r M/ f)t~th ~w>~~
_ i~ (o' s r~'~" lv: j>>~-~'~-/L/63-
~ A PAR7 1~ In.m~.lute fa~ce J IF ntn only Am' r~~v per i~~r~ I(x (s{. (bl. anA (N. Pka~e Prnt tnarvM i~~w.Yn f
7Id 11 f~rn~,
/iJ-~G' ~~'Ci~~-^-~Y~ O o~vt~wl~k~ wnJr
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' ~ Ow to a ~s ~ co^~Muence o( . i nme 90 dars
pf~o. to desm~
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z Ovecoor»acansea~e++QOt - - _ ?Yes ?No
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, W ~ PAAT 11 Other i~gn~t~nt eon/d~t~~ons ~ cond~t~ons co~tr~but~nq to deatA but m~ related to puu ~n PART 1 ~ 78. Wx Autopsy 79. Y/as case referred to Med~ill
' i {~~('~/Q petftn~nt~e_~/~ E:am~ntr~
~'v~: rK.f f_] Yes 1Y~~o U Yts ~i-T'fG~o ~
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30. Reath due ro [7 Hnm cde 31a Desa~De 1ww In~ury octtxred 316. Datt of tnjury 31~ Hour ot in~ur~
I C) A~c[fent (7 Urde~ Investgatron •
i 1 Surr~dt L Orhr.
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FF'. ~a ; 3~d. In~u.y at Wort ~31e Fixe o~ Injury O OMKe Bu~ld~nq 31f. locatqn (No. a.d St) 31g Gt~r or Toqm ~ 31h. St:te
~ I7 Vrs ~ i No C) FM~me C7 S+rce~ C70the. ~
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•.~.e• [J Fxm U Fxtory
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(1151NiH~~1u~N
. Lot 6, Block 140 of South Port S. Lucie, Unit 8, a Subdivision according to the plat thereof,
recorded in Plat Book 14, Page 26, of the Public Records of St. Lucie County, Florida.
PLF.ASE RECORD AND RETURIV T0: 7119;~:9
Gary L. Rudolf ~ ~ ~j A9 ~27
English, McCaughan ~ 0'Bryan ~
1Q0 N.E. Third Avenue/POB 14098 J~~
Ft. Lauderdale, Florida 333Q2 FILcC
ROGE~: ~
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