Rockwell, Walter Order by Number
Form S.V.S.
(Always write with black ink) TRANSPORTATION OF CORPSE
i,
1 PLACE DEATH STATE DEE4k ENT OF HEALTH—BUREAU OF VITAL STATISTICS
1 County ' State.li • NEW JERSEY Registered No
1
Leete$4-44--*Ineroor--441".....,
Lt.I Township ..044,4rtielLegfeelAir.:404-- • or Borough
=
City No. St., Ward•-•
death o red in hospital r institution, give its NAME instead of street and number)
(L.
2 FULL NAME alltCe • If a veteran, what war? —0
3 Residence. No 6.Nrcg.._3}A-a-04%& ao-c.. , St., Ward
(Usual place of abode; in institutions, homes, etc., former residence should be stated.) (If non-resident give city, town and State.)
Length of residence in city or town where death occurred yrs. mos. days. How long in U.S., if of foreign birth? yrs. mos. days
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
I,p
,..."ill 4 SEX . 5 COLOR OR RACE 0 I Sit!gle, AdIarried, WidowedtDEATH -
17 DATE OF
6P . 27 19
o rbrioi trz. (114 4 4 ov e hewr
..., . d)1
18 I HEREBY CERTIFy,That I Utended deceased Irwin
U ry .R. Ak
..E 0 7 If married, widowed divorce 2
X HUSBAND OF 6 r I last saw h ie•hif ali 19Y to
ve on ,d---/- 7 , 19..fk"death is said
11.1 TIT (or) WIFE OF
(Give full maiden name .
' to have occurred on the date stated above, atratett-m.
U
Z ..•4 8 DATE OF BIRTH The principal cause of death and related causes of Date of
(month, day and year) JP• /?.. /g 74e. i portan e in order of onset were as f llows: onset
til CI. 9 AGE Years Months ; Days I If Less Hrs.
1 Teen Day
Min.
LL.I et
- --
I-•• Trade, profession, or parti lar r
•
et a 0 kind of work done, r litorehovelit4?&.4.?fee.Arr44 -.. .
0 rjj g sawyer, bookkeep
, it.....
,... .1 Industry or business in h __. .
1.1. ,... C., work was done as silk I -
Isaw mill, bank, etc. . .. .... ._ ...
,
Contributory c uses of imp rtance not related to ff
CI
0 Date deceased last worked a Total time ( rs) principal cause:this occupation (month and spent in thi
Ll.1 year) ccupation . '
11. BIRTHPLACE (city or to .
-
- -- ---- - --- --- jj Nairie of operation
-r‘ (=a.m..- ...a=7(.2.."1
Dsite of
P NAME What test confirmed diagnosis?
cd 4 "' t e „,....---..„
heran autopsy?
13. BIRTHPLACE (city or to . ... .. . If
(State •-e ntry) death was due to external causes (violence) fill in also the
c..- r .9' .
Z , following Date of
j my.:, r
0 et w 14. MAIDE ip,' , ij, • Accident, suicide, or homicide? in'
.......____ Jury , 19
here did injury occur?
d "••
LI ' 13a. BIRTHPLACE (cie' 111 . ir. "
o •
(Specify city or town, county and State)
tink X (State orL__Country) _ _ • Specify whether injury occurred in industry, in home, or in
C) is SIIGNIOVRRIEN'Irrno .. '0 r Ar- public place
0 (Address)
1.i.. WO )4 . Manner of injury
Z 20 PLACE OF B1JRIAI Nature of injury
LL1 Cremation or Remova e / 4 Vas disease or injury in any way related to occupation of
N J. Li se No. deceased?
X-If so, spec' _DIRECTO', . 1.4_... . .. ..... _. .........
I (Addreif i _
_._ (Signed) .•
16. RECEIV:is G - ---,:rn-R„--p-riscprachrgrit (-Addres . . .... .. .
PERMIT OF BOARD OF HEALTH OR REGISTRAR
This Permit with above Certificate must be presented to Initial Bagg e Agent and delivered with body at destination.
- , 19
Wissi n is her rant to r ove for burial at .. e,44„,.. . it ta.k./. , the body
of ' • , above described, if prepared in accordance with the laws of this
State.
ROBERM-V—e Health Officer Officer or Registrar. oft.
Detach above portion at this perforation and hand to passenger in charge, to be delivered to the iinclertaiter at clectinstinn •