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HomeMy WebLinkAbout0780 ~'73495 ~ ~E:~~ ~~~357 ~ERYIf1~ATE OF DEATH qStMCTM1pM ~G'08 '7~~~~ t.i;vgER , .iAiE Of CAUFORNU-OEPARTMENT OF IUBLIC HEA1Tl1 C(RTb~C~TE Mi4lfR _ Z ' . 1:AME OF DECEASED--r~asi n~~U. v~ap~t NxrE ~k. lAST NAYE 2~ QATE OF DEATH-rowir on. ~ua ~2a No~M - i ; - _ ; Mae ; ; i - ~ ~ , , ; ~ • ' r ; i - ` W . SEX ~ COIOR OR RACE S- BIRLHPIACE ~p~;~T,~", 6. JATE Of BtRTM 7' ACsE"~' • V~DV ~ r~q ~s uv~[11 Za MOyp : ~ ~ - , - ~ ~ _ 1•~es~ Virsinia ~ ~ ~ ; , ; ~ - ' ~ , rE~RS ~ t . kANE Ah0 BIRTHPLACE OF FATNER 9 MAIDEN HJ?uE ANO BiN7HPLACE OF MOTHER q. cnu[H or w~ur courrpr tt socu~ sccoatr ~wweER f r = .~o. cord. ~ no record USA 233-3~-5765 s~ ~ ~~~~~J~Tp~C~ 13. ~~i:i~uccN+•1~io~ 11 NIUIE Of LAST EMTIOrWG C01tiMlr OR FERIf r~:.n~•n••u 1S IUN~ OF WDUS7RY.~ 81l$INESS ~ _ - i ~ ~ s~~ Wa on ~rdneel Resturant Resturant a.' ~ !D t'~iWSi o wq "M ~'iqf uwY~`ci f~• oowco ar ~ow~io ~~~~~~0 ~g? NAME OF PRESEHT SPOUSE 18a PRESENT OR LAST OCCUPATION OF SPOI:Sc `i' • u _ ` ' . . . % . - - ~ ~irlise I~?echanic > , r - - - - ~7 , - ~::a::x: 13t. C.3: ACL'•^.SL_- : . . _ . :s r_: s a _ :s _ _ GO . . n,' _ 'r• _ . ~rfs~c.n oynw•m _ - ~ , .,.:R y;t...• -.~_~a,. . ~ ;(,Ili , :_.:_r L-tn ~ `~.,*`+~a~y « `~nw.o~a ~i ? r- ~=~i~ n~CRY~O~ 19a.. COUNTY 19t lfTIGTX Oi STllt W 19/ lEttGiN Of STA1' rf : _ „ ~ ? . . . n`y,'f~:. • „~yi rY , COUXTY Oi DEAT1 CAWOitlA~ • _ _ ` ' ec`.' L; _ _'Y~ 1 , j. ~ ~EARS ~ fE ~ SW RFS~GENCE--514EET ~oAE55 .4.i s..u 20~ K ws~tt urr ' ~r pirs~pc un co~?ouit awn 2ia. NA4E OF INFOri~tAYT ~r omr Tew s?ptS[~ i ,.J~c~~iilR.~o+w.a. w~ o~a a¦ru. caewiurc u~n oa«o.a m ~ ' . - ` " . ~ C3~.~..~.. p....~. nw,a..~. John L. Wicklir,e < f a S~ ,~Ca OR TOWN ' , 200. CWNTY 20c STATE 2U ADDRESS OF INFpRlIANT •"'^O1•""`~'~'p`^io1Pif } w ~onw. ` , ' . _ - ~ - ; ~ 545~ McDonald , Newark _ . 2?. PNYSIC?AN. ~ wt~[~~ cc~+v~ rH~~ p~.~ir octuw~[O~~t ~Nt ~OUw O~t[ ~MO KK[ f~~i[O Z~C ``M S!AN OR CORONER-SI:rpATURE KGNE 011 i11tt - iat rwo.1 ~wr t.usca s*wrao Nia+ w ~N~~ ~ ~ircwxo r..[ wcc+sto rwor j..,.C ~ ~ ~y.' . , ~ /1 ~ w ` . ~ ~sT s~w t..[ Fec!.u0 ~cn[ c~. ~ • - • J / / • L'f L ~ 1-' .~.1 l 1 - 2~. CORGkER e~..~r. rw~. e~+... ccc. w..co ...t ..ow~ c.•c ~.e ~.K,e s+~reo 22C. AOORESS ^ 22G DATE SIG!(EO " • ~iartrw.~~..ee.vsese~~.co~e~o~r...oTw*~.~.~e~qq ~ ft • - ` " ~ a'- - - - - -;._~t~Q~~i.swo[c lsao.s.couu~[o~.uw ~ ~t~ ~ t • v~i..~~,:.~• 1 / - . ~::l:~.~,: ' ! . ! t ~ Y[CU~ M~.~t •I~t.l~~~l~t } ' ~ 3. ,.;K.~.~~i a~ 21. DATE 25 kxME OF CEM~TERY OR CREYATORY 26r BALMER- ~ tua wo.ai?uu~ uCEtsE?a,~rtE~ j _ _ ~ removal 11-22-6G Forrest Hills Cemeter - ~ ~ 3~18 # 11AME Of FUNERAL DIRECiOR „°R~ '~'."i6 28. *°wp'„~i~{`?.ccwi~aw~w. 29. LOCAL AEGISTRAR-SKNA ? _ . . • - ~ i , ~~,3 :i~ft`~. • ~ ~_,~:~r;.~.1 (,~~i2lG,{:1~7'- - ~ ~ - < - - a _ CALSE Of DEATH cwru or~r owc cwsc rcR u.c soa ~u: ~u, uw • i a i PMT L OEATN WA$ GlU$EplY: p 0~~~ ' - tM~E01ATECJWSE~?~_.__.. C3Y~CI~.aC lc~il~ul'e 1NTERYAI _ n ~ _ s _ g~ i ^ - ` coraiar r~atherosclerosis o~ ~ •N). MMICN puETOU~ ~ : ` ~.,«.o.K ~ ~ I 4 °e"T•" ~ _ . ..o„~~.~.~ J ~ _ ,t p fT1~TMW TN( ' ~ ~ . Z VMO~~L~IMO ~ i ~ _ ~ t~..s[ut~ WETOKr_'-__---- , - - ~ _ - ~ •rkt L. J~~crc yronuK.Anf ~utilHl.oNi CUntKfy;li;NG TU UlATN 8UT NOT NlIAtEU 10 TNE TERYtru~ p~F,ASE CO!.WTiJh GYFN W PART I~U i = ' ` s c c ~ c- OP~R1lTiON-tkECR ChE 32 DATE OF OPERATION 33 AU~OPSr--CMEU oME~ : n~ut~y~EUO~~I?- Wle~tC~n~rMp?- ~1r~0~3tnM0Y/f.- b1MftMVWO- b >~.r114C~ I:~.:KSfO~Y'Si~r p ~]S1~+AK1~Y~~ ttllf~aK1K~~! t l Z ~O~tvtq~ Q~~'l~~'~~:~K`~llt~~~l ~ iIT~~Yi~K~lC~lit~t~~ Q lu~as~ ~'p~~t~t:w.~M~l11~T0 ~f ~XI~NiM{~p~[ ~ J I~~~J~~[~ [~~'SISVp~~~ f~.~SiSWM~iU itnWM~ [~~KSC~l~~t~ 3'~~~[YR(]ORII~ S ~ ~ SPECIFtl ACCIQENT. SUKIDE OR NOMiCIDE 34~ DESCRiBE HOW iNJURC OCCURRE~ ~..~+~w.w~.~...+...~a.~.~.u.++.• wrra.rnrr~rowoyrw.~m.r~nw n s - , _ < < j ~ i~ TtME wu~ rc*rN o~~ .w • F UiJtJRY ~ r. i~ WJURY OCCURRED 35t. PLACE OF INJURY iK,~ pq~~~ ~',,,"'~,K 3'S~. CI(Y. T01IYN. OR IOCATION cown sT~n ~ wiat ~ ~ot nat ~T ~0~[ ~T rO~t ~ FfLED aM~ =~:G3~OE0 ST. LUCic C~OttNTY f~A, ~ - RO~cF ~.)~'RAS " ~ C?_E~K c .~;;1+? ~Oi~RT~ ; Rf^.fRC~ ~~~'-~ra: • x i ~ ~ 2 oz PH s1~ ~ 2'73495 eoa~~~ ~ 7~ i