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i~f,r2iii Fi~ .t:;~+,1f T;1N CERTIFICATE UF DEATH ~ ~
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Cert~ficate No. ~ i
' tp~ 1. NAME OF
aci ~s~-,"
0 DECEASED ~•1,"~ c?c),il.J s~ -
~1 ~rDe o~ P~~nt) (1'~rSt Namt~ (t.1i0A1~ Ndme) (t.2Sl NJ~~tlj
MED Al C FiTIF CA7E Or DEATH (To be liltecl in l~he Physicianl '
~ NFW VQftK Cli V;b.
Naine ol hOSP~ta~ or ~nit~tut~On, ! C. I1 in t~oSP~lal (Clicck)--~-~U. 1~ rnp Jl~tnt d~le ~~1~ ~
It nOl hoSpilal, Strtlt J(ldrtiS . ~ ~ ~pq c~i~rPnl aA~i1~ sin~~
~~ACE ~a. E30ii(~'1G?1 ' ' • L i _khitpat~cnt ~ hlpnln . ()~y # Vear A
()E
~lll , . 2l_iFmerg. Rm.~inP3l~Ent
6.RoN no.~;~:~~~tie ' `i :~y 'e~
3L DAiE AND (MoMn1 (n3y) (vcar) 3b. ?~UUR 4. Sf_X 5. !1t'VFt~~XIMAtF_ AGf.
/lOUi2 OF + ! ~AA1
DEAtN ~O ~Sr G 7 ( 1 UPM ~
6. 1 HEftEflV CER7IFY THAi: ICI~Ctw Une)
C] t allenAed l~e dtct~Sed. C~A SIa11 phys~t~an ol thii ~ns~~~ut~o~ altendecf Ine deceased.
[la~. ~~L ~~N w•~~ ~ attcnaeo t+~raeceasea.
lrum ~7 I~y 19 °a.1.~_to ,.r 19.a~Zand last sa v h{~...a~~~ve at ~Jvl -
on _ ~ ~~A y 19 Iwtner ce~t~ly tnal lraumat~c in~ury or po~son~nq p1U Nc)i ~layJany pari in ~ -
caiis~n~ tlea~n, ,~nd that Aealh ditl nOt o[cu~ ~n any uni~s~~a~ man~~er Jnd was due ent~rety lo N A T U R!t ! l' dl I If5 E 5; ?
•See tiut ~~struct~ N on rq4er o~ ce~t~t~utes.
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~Y~tness my r,and ln~s .6~ day ot ~ C:~ e~,~ 19 .~.~..~S~qnature / h1~ ,
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Name o1l~hys~u0n ~-i~fC r~1n+4,.tlC adA~ess s+~.~sC d~.,-~l Nof n~~~C
~ f ~ YDe t~r i~~~nt )
- PERSONAL PARTICULARS (rv be /rNed in by Funeiai Directo~l
7.USl1/1L k~51UEt~c_~ •U.(:()UNiv ,c.C11v i()WNUft~ ~.tl.STHLEt ANUHCit~SE NU~.iD~~- ~'~e.iN ID 1 Y
a.STATE : LOCAtinN ' 4 ~MITSOF 7c `
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~l=~.l~ G'rl ' ~.1fl1StL`t1c~yC~, ~~0 jv `I
L-!~ S ' S~7 R ~/T ~/..r- ; ~vES . ~NO ~
I~1l1{21TAL S1 ~1T US (Lhttk OnC ll i IlEN (~i ~Nf~A i L~~~~N t NY I0. NA~At ()i~ SUi2 VIVINL: Sf'(lUSE 111 w~le, g~vr n~a~den n~~n~) #
~ 1 Cl Nerer Mari:eiJ
2 ~h!ar.~eU ar SeOa~ate6 ^1,!
3QY~~tlowed 4 t:Chvor<ed !.J . 5.~. ~tR r ~U ~L~~~
. 1 L ~MUnu~l lUay) fYear~ ~1 I1Ni)LR l vca~ it ~ESS tnan ! Ol1v
UATE OF ltGt A7
81RTFiOF~ LAS~ ~ ~~O~thS . Uayi 1~outS ,Min.
DECEpENT ~ ~ 7 . (Q~~~~ B1RT?10AV (p ~ •
~ 1!. USUAL UCCU~'AT ~pN ~K~ntl O~ wurk tlonC tlur~ng moSt ot ~ b. K~ND Uf ~US~NESS 1a.50C1liL SE~CUR~ iY NO.
w~~rk~n4 I~ICI~n~t; c1o not en[er rtt~retl.) ~
1
t~ , c r C ~ v i'~ ~ ~ ' / ~ 5 i 7~ G1 y9 -/l G1 / "
I5. Blft f?iNIACC (StJte ( ore~g~ Counl•/~ ~6. pTr~EH rann,~E~S) ElY ~v~~it?~ VECEUENr wns rcr,own -
i
~ h/~ u./ (1 ;
ll. fVA~hE C)F F{lfftf_(~ t)F VECEUENi 18,MA~l~EN tVl~ME O~ MOT1tER OF UECEULNT •
[I ~SC h~ C/ lt/ ~ E/l//`~ ~f O f/ ~
19a. Nl1ME f)F INF ~)IIRAANT .b. ftELaTI(3NS~itv , t.liDU?"rE55 (C~fY) lSfate?
, rO OE.I'E-n5E0 , . ~
b ~ R 7-" O ~ ~U S/?jf') itJO ~ f ~ f~ UC R C L/~l /LrL p h/~FR , ll~ }~r r~( '
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; 1U~_ NAMF tlI CtMF t t Itv ~~t LN[~MAi()ftY ; D. LOCl1t~()N (t'~ty, TaN,n, ~tate and Counlry) ~c. UATE~ (lF BURIAL OR - -
K',w : cuFr,nnriorv - ~
~ fi- U 1 ~ ~ ' ~i,t t~ ?~1 /9 C.~./= yc• s ~ ~ " a 7 ` ~ ~
_ 21a. F+JNEf+At_ l~~~rt +.1~~i+ , b.l1Ut)f2ES5 ~ .
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' /f~'L~l~~~f'/v `'1f= />>nr l~c r' 1~ t~ P%~ ' /~$~.t . T,v'c.~n~.i~CK `~s,i~2s. t~~; . - ~
BUREAU OF V17.'1L RECORDS DEPARTh1ENT OF H~ALTti THE C17Y OF NEW YORK
.
'~6~312 -
This is to ~~ertify that the foregoing is a true copy ef a recard on file in the Department of Neafth.~~T e~C ' -
Department of Health does not certify to the tr~th of the statemcnts made thereon, as no inq~iry as !Q the ~~~~T:~,~~ -
facts has been provided by taw. ~ ( F+~~~ r .
no«c~a
iRENE A SCAMLON ST LUC ' s '
CITY RE(31STRAR ~ .
~ Go Not acce~t tAis transrript ~~niess it b~ars the ra~sa~ aeal Qf ths Department ot Heaith. Tt?e r~pro0uctbn or enEration +
u+ Ihis transcript is prohibited by Section 3 21 oi the Hew Ywk City Heafth Code. OF .
BUREAU OF_yLly. R[CORpS OE?AltTMENt' Of HEALIH THE CfTV O/ kEW YORfC
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