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v O 1CE OF THE REGISTRAR OF VITAL STATiSTICS
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a~ MOUNT HOLLY TOWNSHIP. BURLINGTON COUNTY. NEW JERSEY
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NE1h JEHSEV STATE DEPARTMENT OF iiEAITH ~
CERTIFICATE OF DEATH
a C ~ 1. NAME OF DECEASED lFinU lM~dOit) /Last/ Z. DATE OF DEATH
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~ 3a. Pl E OF OEATH (City a Town) 3b. County ~s. Resdenp (No. ~nd St.1 4b. C~t a 7owr+
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i 510 NC 2 ,
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$ ~ ame ol Nocp~tal w institut- i~i rqt tither, qire No. ind SL) ~ CountY ~d. $ute 4e. 2+p Code 01 Ins~de C~'y Luniti
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R'C Q ~ ~ r56 '+.,spi~al 6~ ~nst:runon. cnet#~ boa 6 Msritsl 5tstus a. Wu Deuased era in U.S M~I~cyY 7D. Wx ;,c
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a d A ~ JA ' 1 Inpat~mt 2 r Mxriad 3? VY~dowrar! 1~'~Ytf ~ MlM YMif ~nd OiLQf ~ from:
w Emergenty Other: t?$inqlt 2? Stpar~ud t? Dnoroed ? Yts No ?o:
.+o5?rtwt o' 8. S~a- - 9. D~tt of BntM1 10. Agt Last BiriAday 11a, Under ..1.. Yex ~ l b. Under ..1.. p.y
; ~ ,~~~tL _ ~ T~~ MONTNS DAVS _~~VUNS NINUTES
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' 1?a. E2~rU.~aca IS~ate o. Foregn Country) 12b. Gt~zm of whst Country 13. Suniv~ny Spouse flf YY~,,te~. iden Nsmel 14. Sx~ai Secw~ty Number
' AGE ~~SSO?i~ ~ ' _
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; 15. Rsce U Arner~can Ind~an 1G EcMie Or~y~n D IW:ican ~ Ot1wr (SCkcifYl 17. me snd Hddress ot lssf)mobvrr
~ WTite ? OtAtr 1$pecifY) O Puerto Rican O Itslian ?
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~ a!FTNYUCE o~i 18. a1 O~uwtron IKmd ot wak dax most of 19. Kngol Bus~ness a Indusdy ~ ) ~ _
' Y d ife ren ~1 retued) ,,/f ' ~t K//~lL~ I? 1~ .
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; RACE a; 20. NAIM€ OF FATHER ~Fnst (M~ddk) (l~st 21. RAAIOEN NAME OF MOTNER (First) 1M (Lastl
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, ' EiHy~C Q~ 21a. N~e of Inlormant _ Z1b. Relat~ ship 21rr~Nurnber xd SVSet 21 Ciry o~ Town---TZIe.~~t~
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~cAUSE 22~. O~spou[an 7 Removal 22d Name ol Cem~try w Ge,~mstay 2~e~C~ry or Tawn 22d. Stsu
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PtACE OF 23a. Na Address of fu a~l Gn ~3b. tu.e ol F al Di~ " Y,ic N.J. License N~.
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i 25a. Namt ard AWess ol Ca.i~t»r- C7 Art~ndry ibrs. a l~40. Eaam. Sb. To of w~y kN.l~q~e. dn~l~ oxur.~d n~ Oan ard co crn~kl sqeW.
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Q i ~t.l,?!) ~ L/~ r/ ! z5c. ou• siq~aa zss. r~ow or 26e, w«ww+«e oe~e
G u ~ Y~~ ! ~ ~~d'!~ ~ o / S . ~ 3 Death Mouw , ~ °7. /J ' ~J
f ~ 27a. ?ART 1 Imm[dyt~ Guu (Enter or.iy one uux per line for (a). (bl. and (cl• ~~Y print Intcrval tween 27d. It fert.ak.
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! ~ a. C-~.~"c~• 6 l, q r/ L, 1- w,set ,nd eeav+ u,~ ine ;
preynant st
' Due ta w as a conse4us~oe o( aam w+~*v
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k time 90 ds~rs ~
c /v P~ O CK~ ~ t.~ ~ p~ior to dea~h~ ~
% = Due to or n s conseyuena of ? Yes ? No;
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~ i M i PART 11 OtAer sig~ilicant aorditiom - oonditiont oont butinp to dtaM but rot tslated to cwse in PART 1 28. Was Autopty 29. Wai tau refnred to Med~cal ~
> perfa 7 E~xmnt.?
( t O Ves No Yn O No ~
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~ J0. Death d.,e to O FiomFC~de 3/s~ Desuibe how in'ryry oonxred 31b. Dste of njury 31c iiour of In'
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~ ~ n A[Cdenl ? Undlt IflYCftgilqn ! ,
~S Cl Surcde C] Other -
I - p N~~ I 31d. Injwy st Wak 31t. Plau of Injury O Oifice Bullding 311. Locatqn (~10. snd St.1 I 31g City w Town 31l~ $uu !
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N:sw , C fxm p ~sctay
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~ 9~~ TMIS IS TO CERTIFY THAT THE FOREGOING IS A TRUE COPY OF A RECORO IH MY OF ICE.
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~ ~ATE F ISSUE ~ Ef31ST AR OF VITA STA K ICS
~ ~ WARNING: ~o NOT ACCEPT TMIf CO?Y UNLESl~TM[ RAIiED fEAI Oi THE OOARO OF M[AITN If
AiI1X[O TMER[ON.
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