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HomeMy WebLinkAbout0613 ~ ~p ~+yq ~ERTI~ICATE ~F OEATH ~ ' ! 3:1C7~ I IV sTwn w cw~~~oK~+u--o:rwwn~wr ar Ncw~m ~ ~ SiL7L T~lI ~:wR~R Ofi1Ci OR TME !?AT< R[OIlTRAI! OF VtT/?L fTATI{~~GS --~L~~$ Atf35T~~fW1 ~dSYM~f A~f~ Cl~1?tfh~ll l~tt.- . ~ ~ 1~ H~ME Of DECEASED-iM5~ ~ hYlE~l~ YIpp~E IIMI[ k ~asT w1Mt 2~ 0~1TF O~ OfATN-r,yrn? N• ~tr. wx~ 1_. i•:t~ ; ~,ll~lARQ- ; '~!1'l'il'IiY J[~1.Y 3 ~ 1 ~j7'] ; t ) SEy_ + ~ COIQN OR RACE 5 BIRlHI~~CE •~r~~s.•.a?.».e+~v" 7 A E~,: w•w~. ~r .ei~ ~ t~~ ~ to~wn.. 6 OATE Of YNI1N 6 ~tai.~: c~~', . r:~~t:<~AS nc~v. 2~, iR~?3 E3 DECEUENI A hiYF AVD NiRIkPIACE OF FATNEp _ 9 MAqE11 NAME AIiU RSRTMPLACE Of MOTlIER ~cR ;on~~ , .,1~ . T ' :L it i :-1Y-1" K?~ C• il`; DATA . •iAlt ~l)l'~~.'N t/<K ~L - ~T?.'h:~T~ :r21 IU t'ITIIEh Of WHAT ~OUMRV tl Spf1AL SECUi11Tt NUYBER 12 r~. ~~t~ rurcr woo~cw 13 NAYE C1f SUAVIVHIG SPOUSE .s ~s~ ~~ta~ rw~t~ w~. ~ ~~~.n 1~~~-o5-ta<,7 ~i'u~~n .~~~sz~ t{ITC~tcc~::~:- ~ iJ ! A51 •iCi.~3PATiC~~ 'S +~~~,:%.ia'~'. ` 10 h~VE Of IAtT EMKO`/MN COIMANt OR iMM 17 K910 l~! ~NWSiHY OR HUSIkE55 . v.~~~..~.u soh•,~. .:ii :.>ilt~~- 5Q .?1:t',!:.c1 _'t.~. ~~V@ Irniu::f'.Y' CS t_~CriE'Y'~1 "C!'C~?`71(~i c(~a ~8. PtACE O~ OF~Tii -•.a~ ~ w~;r~tK ;w un.[e ~~?ar~ENt catnrtr ~te~ S7REET ADORESS--~sr~efi~rsws~a ~a.ur.r:,? ~8c ,~ux c.~• ccw..w.c t,r~~s I stn+`.,~snw ~t ~cE ,''~216 CA;t~'t:~ ~T:: i~?'}: ;~A ; ~"T~., D A'TN - ~ao Crit ua ~GwN' ~1& CQUN~V ,~b .~K - ~ • 1•n r •'~ta'~M M~~• ~~8: _ • - F ' ::!~U.•':?(`~ :~i:ACtl ~ l.C~r A?~GEI.ES ~ 3 ':/h:; , ~ R . 1 .s,~as . ~ a. JSUAI ,~Q~ U~UAt RESI~EhCE -StREET ~DARf55 :r~.v uo wwkr ps i~~nOr. 19~ tNLpE flT~f CpOpla(E ?~~1!TS 20 hAYE ANO Wl1LINC~ 4pDRE5$ Qi' WFORflANi Rf$IUENCE ~'f~~ " ~ e ~ • ? •f ~'faar?ttSa~w:• ~~a..,,«~.r ~~-lh xfT:. 1::`..~1? ...1 :1 ; YF:S .)essie *•iur~hy ~.nm~*+o.~ ~~.c, f9_ C~TY OR iOWN ~i9o CouNTr ~~9~ STATE ~~I~ f:Rl•ne~;ie Lane,:r~+. ~`y.~:~` ::i:~'~ ',~:11~N ; l.t-:: _1`:trN,l.E.:= ; C:~L,II~'QI:'~7~ K~cton~o Reach, C~. . ~0278 Z1~ CGR~~~£F ~ e ~[~ta ui.a. ..i• 1ua ea.+w~ i ~ 2!~ PH~SI:JIN i: peru ~M Oa CO4WE4--sc..•,.i..-:•.~e i21o DAfE 51GME0 •V ~or~ tv. •N nk~ ~r~Tt~ Vx~ 'r'N!c~C+.ANS . .:.•.•~..~.~'..s.•.~:..,•ss~.~rax.~~r•..- .•.~.~o•r_tcuv~ ~ OR (:pRONER~S ,K r~ ,o - _o M.~ , ' ~ ~ ~I77 i : . , ~ ~ wi.n. wr P'~~ Ra~ M~ n~ ~.~y~~~ ~ rER11«C4ilON i~ ' ~~~pp~ 21~ A 2~s sx+or. ~ ; ~tt1y .~o ` i3~1'1 ~ z - tt i ?K1~~1>Y~ ~ _ . ~ , ~ ~ ~ y i ~uo u~• i s s , ti~~~,..? . ~ z ~4-f4~ FUNEHAI 22• aY:,~:..•. tti-..rrrni ~:2• OATE 23 NAYE OF CEI~TER~ OR CREMATORr 2? EM8/ll.MiR--s.f.?urtHC •K MiGt trp_~L UCE14F ~q~iP ~ ~ T4'!' • ~ ~ ~ ' DtREC~OR j~~~, . i~_ ~ 1 U:. ' i-7"1: 77 pA~i=~~'i ~~"T;M•.ri',?~ aNL - ~ - ~pCA{ - ~'tta~~ ~c~a, ~s 3u:M~ 26 wcae. w 21 REGISTRAR 0 Vk ~w fi'tiF~~: OM[.••)q.,,~ ~!u~• ~v•~o.e:ar..~r ~a ii~o~MMSSn.~.~. R ~ RE6~STR~ ~ .J~ L-~ ;~~~r'.::Y i'1 ?~}{t~i~Cl'i ~ .1~i .Q/?~' ' fUl ~ 1977 . ~i IQ FAPT • Df~T- M~5 GUSED B~. ENfEP, pl~lr ONf CAUSE YFR tME iti.7 A B avp C , vrFp~t[ C~•hE j.y~ ~ ~ ~ L ~s~ U!c t~_~fl~~ `'r, ~F 1 q ~ ' r _ ~:E TO J5 ~ COMSEJYEMLE Oi !h'ERY3L r-f (.AUSE - :ti~ wti: ~,E.ffFo. Q~ Wvk ?.e`T '~•E ~YVii} ~:8~ ~i oF .•e ,-.,,<t . 5,,, , - ~1~+'~G ~!s-rlWrG-~-. - oss~i ~r,;£ C~fi ~S ~ CONSEOtlfNLE (~f ~~O ,5.. i OEATM r~c :,~cca.• ..E ~E.-ti 4 ,,.,T ~ r~i o sG/c~ o~% c~ /~tw t ~,:t t-,V~(~,% •~O FART !1 ,)!M[R SIG\~fK~lII CONpT~OKS- c..~•.~~~w roet~....• r...> c•~. ~ww~h <ir[ uw~ r ryt.. 31 usur~~are~as rrs~nr.~.er~t+ 32~ ~c ~r~ . w+ta -r ~.w~o~wne.ynanMac•.w:, .~r:r.~32t .',~w-•.~.~•...w. Q ;.~uiaw~~.e+ri.•. .~....v r.arar-.v~~n.n.a«c r /V'b /1 1 ~ ` 33 S~f UFr .._~tiT x,.:_ cc o~ ..owno: 34 n•ct ar wu•i •~•:•a+• 35 wx~Rr At w~~Jpc 36. u~rE o~ ~n~+mr-- .a.. ~ r..:.n.wvr•. ~.~....,,....:s-N:r .+nc,..~:..~~e. ~d6~ HO!?R J ~ ~ ~ n ~ ~ w' ~H.;uRY 37• PtACf (iF INJUR'I ..:Ftcr a~o ~,.au~ .~R aa~ncs ~ro u„ o~ ror~~ ~37~ ~1MK~ rv 4••• , 3c u~;,~L~•~~~l~~,sYt•'I ~~~O~RI 39 ~:i:: rhS'. - _ ~~INFORMAIlON - ; n..~~...:n,r c..<: .r~rr~ ~ +kES - 40 CESCP.I6F NOM .~~uA• CLCvPA!: ~a~cxa-aw.r~a...o,.wr•._+~c~:~,M• v.ra•.~~r+sw.or~n.~r.~n~~as~ i t 57ATE ~ B G D E F . 4tEGISTRAR ~ - r_ ~ . ^ ^ _s , , . . - ~ . ~ - - r ' - t: ~~~~C ~~QiT~;Y ~A .,w? _ - : F~~GLi~ r`01; R Z~ . j• • " = L' . :L'11 ~ , r# l = R . ,u~ . • iH~S 15 A iKJE CERTIFIEO COP1? Of ZME RECORGI w~ F~tED ~IN THE COUtItY OF ~OS ~GELES DEPARTMENI • . • . F HEALTN SERWCES IF li oE~RS TM16 SEAL ~N ~Y~ 5~ I~N'~ . • PURPIE IiVK. , F E E ~ • , . - Jul. s ~~77 ' "3981~ ~ _ ; _ ~ ~ ~,'~'~,,~~~'~'..~,.~Z~.~ . • ~ ~~~'"C•. N ~ f ~"~y i M«nsos E CM+obuM~ Acw~ OirK~a~ o11M~t~ Sa~ ~d R~strat ~ ' • ~~`~r~. ` a~2~4 ~ . Bi3. . - _ - - _ _ ~ ~«~'~.,~.c~ ~ ` _ . _ ,