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HomeMy WebLinkAbout2664 c ~7194/ . CERTIFICAT~ Oi p~ATN ~ 9 7- 0 4 8 I 8 5 ' S?ATE Oi CAI~O~IM--0[lANi11EM Of MIKIC MEAITN NAIIE OF OECEAfiD-~ w~[ M ~roo~t ~rt k. W? Mw~[ L OAIt Oi 1N-~~? a.. nu ~b. Nou~ ~ r ; ; .r- ~.%11.ly /~i7.:~' ~ ~z a sEZ a. ca,oR oR IIACE s. Mrrwucc s o~tc o? w~tN ~ic K , K • IAI,F CAVCASIA ~`ONb'k'CTICU'l ~)CTn9F.R ~ 189R 7•5 DECEUENT ~ NAYE ANO Ni11fMLACE Of iAlf~ ! NAIOQI MAI~ ANO iMT1MtACE OF ilOT1~R QERSOr~~~~ ~`~l17 NORNSTF,IN RiISSI~t Pavr,INF. UNKNO N RUS. oAT~ q CrtIZ[M OF 1NNAT COUN~R~ 11. fOCY1l EECUIri1f MNNEN 12 r~~ nvM r~~ru? wro~w q. IMME Cf lURV1YNG SIOUSE ~r ~wn o~a ~ww ~rp ~T11D101Mt1 ~ ~~c~~ II.S.ti ~iRRt~n NaT ~ A ~o usT occur~na~ ~s ~„~'.Q:..K; ' K~~~?Ms~~ar~lor.K o. n.r n a~a os oR wswESS . L3ROKER YRS iI~'?'ROPUGITAtI fJORTGA 1~ c ~A. PlAtt Of OEATH-~urE as MoswtK w orwt~ w?nnar ?~a?m ~qa STIIEET A0011ESS-~nrn r ~ww o~ wuma.~ 1 acwr~.a~ei:ooMa~an un~ '~`oFE SF:PUI.VF~A VONY HOSPIT~lG i~S1~ Sk'PUI•Y•~DA B i~D i D E~ TH 1i~ CtTY OR TOMIII ~ Mt COUlfir ~ IM- u.aw v a~. ~ s~wn a r... ~I~s .ar.. v wu. cr+err 1 I i~AN NUY.~ i LD i~'ICF.I.l:u 1 2 usu~~ ~s. usu~~ ~o~cc--srnco ~~~...~.•.~.~..o~o.~.,~o.~ ~9. wsoE cmr oo.ro¦.,c urn ~+u~ uo wa~c ~oo~ss a r~oau?ar ~ n.ea.. w a. ~o~ R~S~DENCE 7rj ~1 vOLDWATI~.R CANYON ~ YE: N..F,'tl'IAN R_VSS. ~a u~rh a:u~uo r ~R~,,n:~, o~.~, nc crtr ae TorrN n. cakrtw sTSrE 391.9 SilPPHIRE ~R. ~st.~.~+~.~ t,RTH AoLLn~?oob Lc~s A.VCls~~.^•" ; wlLIF~~RNI .~'NC NO ZI~ CORONEI! ' w ' 2N MiYSICWI ~•arw ~w r..¦ «cur~ tk fMYS~CLr O! C01101lE1~ rs.~w~ ~ wwa 21e DATE SIGNEO y~.¦~rc~rnu~r ~ w~ rea w r.~u a~n~ rw j ~ 1 / ' Y 57 ~'.1N $ ~ i i~a.u R.u a.i ~.ui•wa ~ ra~. r.a u+~s wuu ~eaw r rr~ ~ anrn na Ma.K~ ( ~ 6 L i r ~ i I/' J .;R i.ORQNER~S ~•ar.rnoMCaw~r~~r~w.r~~~ru.r~~w.w ~~~YNw~Y~~IY ~ ~ .++scr~cu~~ C~RT~FiCATlON ~ ~ .nlff~r. A~~ ~21r..i..w.iw ~~-~y .s-~~~ ' ~ 9 22~ srccw~ wra~- aeo~rr 2!~ OATE 2~. NAME Of CEME?ERY OR p1EYATORr _ ~r ~t ~ tlri ~ f i1': E RAL o~ c nor 1 CIReC~OR '~'vHra~, '11 25 7.i En~:rr I';~rrnRl 'P.~kK ` ~ 25 rur[ os nwElw OM[CTO~ ~o~ ~OlOII klrs u lYCr~ 2t w~witi~°ar.: 27 ~ r RwG STRAR ~ ~ ~.nc...o...~• ~ ~ _ I GItQI1AN EDt.N I:ORT U~lR Y ND ~t ~ ~ ' 2! VART t ourn rnt wata rr: orr[~ oKr oMC cwsE rq u~ ~M A. - ~ ~ rrEOUt[ CwsE y ~ ? ~ LI % ~ ~~MnOi~ ~ rnn q1E t0 OR At A COMSEOVtNCE O( ~~a~SE . cc.~,nroNS ~rµr wwcM • -s n( ~EtMit01 Gavf pKE t0 1ME wrEW /~1 l+-+ /.-7 - aT ~ L~s~ /7J~ y qIMT , U? 1 AiE CAUSE STATIIW ~ ro ~~SEOUENCE Of ~ ~ ;,'tA7H UMOENI~~MG CAYSE ~ . t~sr (C 1 ~ tM~YRti tD M~~11 w~ .o. ~unr .o .r ..~wn ww o.~¦ ~..rr r w~eoa~ a~ w,a wr+n w~ ]L 32~ r•n wr rr+r - ~30 PARi q OTNE11 f1GYiKAMT CONOfT10MS-- r.w~n+.~~nanMr.rn~~ .rec,n~ - wr~~ OKY~~rMM~r ~O~ '~Yl~IMM~f~r~~t/1A~~~ L ~ ~ ~t ~7~ [ s. I~? _ ' • ~ ~n~_ . ~ ~ s.a ~ ~ , y'7 - v~r. ..w .~c , «na M+ .ar HOUR 3~ SPEC?iY ~cc~cn wrc~ o~ wwcr[ ~I nacc w wiwr :r.... .c.... •.y~• 3S fMJtl11T AT fO~R oA O~ ~MJUR?- ~ ~ e..c. ~w.e+a nc . •fnc...u e..o ~ ~ M . "uURY 37• PLAGE Oi WJURI' ~n~cn ~w wn a~ ~ouno~ a+r cm w raw~ ~37~ "",~w"~ "~`c.or.~u ww~.s ~ 3~9.` ~,`M "w.. NS»f~U ~fY h ~ Il ~ ~ .~,~,".~RMATiON ~ ~ IU D(X NNE NOM IhJtMr OUlNMEO ~~•n~ ww~w v~a.~s .«c. rwn~ r r..~. rhA a~wr~ row~ ~[~K~~ r m~ M~ . i, - ; ~ s ~ o E F - ~ _ -•-aRa 2~~.^~ ~1 # , fIlEO AN4 RECOROEO - ~ ST:IUCtE COUNT~? flA. ; THIS IS A TRUE CERTIFIED COPY OF TME RECORD ~ ~ ROGE~. ~d~~RAS ' FIIED IN TME COUNTY OF lOS ANGELfS DEPA~TM~tiT ~ CLERR Ct~.CUIT COUIIT ~F~ORO VEFIf1ED~..~..~~` ~ OF HEAITH SERV~CES IF IT BEARS 1MIS SEA~ IN ' ~ ~ , PURPLE INK. M ' FEE P 1`l ~ PM'?~I ~ oy,~.~: ~ ~ ~ ~l ~ ~ . ~ 1 ~ . i ~r . , . . , f ~ . ~ ~ tisee. A. Irn..iN. Ob.au d Haw Sa.+w ra Ibd. F ~r ~ . _ . - .•..`-a' Na a-~~" ."`v~..~"x,' a..y.s~' .:ti`' e-r ~ i _ ` ~ ~ . _a,._ i. _ ~2..'__. e_.~..~