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OFFICE OF 7HE REGISTRAR OF VITAL STATISTlCS ,
' ~5~210 oF
'87 NOV ~Z PZ ~~3 MOUNT HOLLY TOWNSHIP. BURLINGTON COUNTY. NEW JERSEY
~ NEW JERSEY STATE DEPARTMENT OF HEAITH
F~~.:-=- ' ~ CERTIFICATEOFOEATH
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S 1. N r OF DEC ED (fbsU fWidd~1 IL~W Z. OAT Of D TH
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3.. u?ce F u~?ni lcar « row~l 3e. cann ~a aa~d«+o~ tNo..na st.l ~e. c~a « rown
Browns Mills Burl. 1298 Viley Road Lexington
5a, N~nr of Flo~pital or Mstitution (11 not titlr. ~ Na and SL) ~e. Countll ~d. St+q M. Zip Cod~ 4/. Imid~ City Limib
Deborah HearC & Lung Inatitute Fayette Ky. 40508 o~
~ se. u~w « ~~u;m~o~. a+.a~ oon.~s eox n wrn.i sna. w.~ aa.~.a.w? h u.s. ~rrna~y ~e. w.? ~a ora
O OOA Q[lepttient 2~ Wnid 3 O wdvwd if "Y~' ~nb? Wr and Dabt from:
O Emerps~cY O OtMr: 1 D 2 O Seprabd ~ D Oiwrad O Ya To:
~~A~ ~ a S~x p, pap ot BiM 10. Ap l.wt 8irtldsY l1a lJnd~r "1" V~ar 110. tk~r "1" Oay
Female March 17, 1919 64 M NTH OAYS M 11 YIMUTL
~2,. e~nv~+~ ts~+a o. F«•~ cow+wl ~ta at~ o~ ~+n co~.,w 119urrMrp Spou~ Uf NF`•. MaidN? NNrr1 so~;,i s.c~.~ro r~
~E ^ Massachusetts 'USA Francis J. Monahan -
~s. e,o. o,~,,,r,~,,, u~e~ 16. EUn~c Orpn o w:~ 70 oa~ avp+rt ~'~"'••~w ~ea...~ a~e Emoww? -
~w~„a o o~. o~ a~ a ~w~ ~erican P~icAlpin' s Dept . Store
unTM.ucE > 1~ 1hua1 Oxup~tion (Kindof wakdon~ mostof
19. Kind ot Busnnt
1~ I,eX3.11gt011 ~ Ky . ~
_ ~ ~'a`y.~'$"rt1id' Retail Store
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11ACt ~ IQ. NAME OF FATHER (Firtt . (MiO~) (lat) ~1. MAIDEN MAE OP 1AOTHER (Firtt) (AAiddk) (l+st)
~Joseph • -
ETwoC ~ ~ Yia Nam~ of Inforrtw~t 21b~ Rt4t~a~p 21a Numba snd Sunt • 21Q City or Town 21e. Stsb '
= Francis J. Monahan Husb. Same as 4a Same as 4b Ky
• cµ,tE " rn oKv~+ o R«~o.a1 ~e, ?4n,. a c~n.t«r «c.«naoory nG Giy a Town na sua
- Calvary Cemetery Lexington Ky
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?twCE OF ~ 23~. Nam~ and Addrta of Fwwal F1om~ 23b~ • ot furrrN ' _ 23a Kl Lian~ Na
~ Perinchief (hapels • • 2883
_ _ 438 High St . ~ - a ~
Q'°""~' Mount Holl N.J. 08060
. ?Sa wwu.~e Am... a c«ca+.r- o Atwyew Ari O wa 6r.. ro a ~t r wnL
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27a PART 1 Irrw~rdita C~ (6~tw a+h on~ tsiw~ OK lirr br (~l, (b). ud kl. p~nt IMrr~l bnrwa~ 4~d. 11 f«r.~U. ;
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~ PART il Otlw ~q?if~iant aonditiau • oonditiont oonbbutiry M dMN Eut rat rNwd eo wuw in ~ART 1 2a Wa Autopey ~D. Wr pM refwnd eo Wdiql
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QYM D No O Yn O No
30. Dud+dw a O I~omicid~ 31a D~w~ Aow Injury ooarnd 31b~ Wa of Injury 31e Hour of Injuy
O Acc~nt O lhdv fnv~stiption
O SukiM O Odrr-
•w. i~ 31d In~ury tt Work 31a Pbn of fn~ury O OHios Buildirp ~1f. loption (No. snd St_I 31f Gty a Towt? 31A. Su~
~1 O Ya O No O Fbnr O SaMt O Orha • '
Mtssa O f~rm O fatory -
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THIS Is TO CEFtTIFY THAT THE FORBGOIHG IS A TRU[ COPY IJF A RECORD IN MY OF ICE.
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T[ f ISSUE EGIST AR OF VITA STA IGs
i :wwa~iNal DP NOT ACC[?T TMI/ GOlY Ulil~~{ TNt IIAR[O ftAL 0/ TN[ ~OAIID 0? N[AL N It
I A//IX[O TMt11[ON.
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BOOK 564 PA~E
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