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4~~94 CERTIFICATE OF DEATH 33 e3~8
STATE OF CALIFORNIA
Si1i[ rq[ NUNe[e tOCAI N[GISTRATION DIST BCT AND t[N t11ICAT[ NYNN[N
IA. NAME OF OEC EDENi-fINST ttt. MIDOLE tC. LAST 2A. DAt[ Or OtATN lra.rr, wt. .t•Ar 2O. r••wA
R. 1 Raymond 1 Bolt .\ugust 4, 1979 i 1020
SEX 4. PACE S. ETHNICITY 6. DATE OF BIRTH 7. AGE ar r*a:¦ r i[u n r.uA t• coos
Yale khite June 2'7,18g? 82 ...a .°..t rrwr[tr
a..a
DECEDENT s. u.•r.a•c. o. D¢:otwt r:nn c. 9. r.aa awo utrr?a.;t or iar"tR IO. Nr RTN N•Nt •Ne NIArw N•C[ O/ NOIMtR
F'cftSONA1 r-'=a:•'~'~rr•rr
DATA Tennessee Giles Holt - Tennessee Lee Clements -Tennessee
7/. [m:[• or rrar tor.r•t 12. Socut S[Lrtln Nvwetr - 11. N•nLa SHTef 14. NAY[ Or SYNYIYINI: SlOYS[ ur rut, aaru
erw tw rawq
_ U.S.A. None Married Loretta Bertram
lr15. ?arur OccrnncN t6. N~rs[r or i[ais 17. trrao.n ur star trnem. so sour ttl. Aue w Irawsnr or bsrrtss
A enc General er ~arra50 Southern Raiiw Com
_ 8 y ay parry Railroad
19A. uswa Na~oa+c[-sn[n •settts as»ati rota o° aocarrowr 111!1. t L U 19C. Urr a iorr
usuAL 2295 Bob 0 Link ~ T O ~oZ Fare Springs
RESIDENCE t9D. cw.r. ' 19E. ar•rt 2O. MAME AND ADDNt SS Or IN?Oe NANi-Itaalrorawr.
_ I Riverside 1 California Spouse
i~ 21A. rLAC[ O/ D[ATM 218. COUNii
PLACE :~esert itospital ~ Riverside Same a8 Decedent
OF t
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..~i:i ii ...,..a .~"waa ,a a„a.,.u.r ~ Yiu. aalr oN loiYN
1151 North Via ;Kiraleste ~ palm Springs
22. OEATM WAS CAUSEO BT: (E:[TER ONLY ONE CAUSE ?ER LINE FOR A. B. AYD C) 24. N•s ct¦i¦ ttroAito
INYi:D1.i7E CAUSE _ o coto.tt'
fAl T Arreon-
C.'I:SE cow:rrrows.tr.wr. ~ ~ NAtE
OF wt ra. o. as • wst.. _ a? INiter•i 25, w•s Aro.s• ?nro•wur
r"~c. u•t us¦ ro si iwttw
DEATH t"t r.wta~art cause, `r
(B) owsti
czar..: r"t rwou_ s°t to, oR •s • cows[wt•ct e? AND
anw. eaas[ a•sr D[Aix 26. eras Aerosr r[rro•wur
~ (cl
23. Oc.tR eoreanos COwTOAUtr.G Avt Nor RIUrrA ro rrt Irrourt Urse o/ Dtarw 27. eas o•umow re•ro•w[N soR •wr eorrrnew a n[rs tx o. ta•
t , ••r[ o t•anow eas[
I
2S r curer i a oar c rr[ Moct. Dart 2 ?M[SI[UM r4war a •wo et% c mat 2aC. o [ srcaa 28D. ? r:raaw•s arc[wst r°wAaR
~ PHY51- •+a re.et s-.rto rtor r"[ e•nsrs sr.eta. ~ / ~ ~ 1
'-IAV•j 1 4^esaro Oretee.r S++ct I 1 Us+aaw Dr[tan* 11an[1 ~ _ 1 1 `v')
CERTIFICA- ~r•r'• b• r 1 r[+a¦ ro. aatea r 2 ti?[ r s N's r_ • ~~-~a3 lil J~~IIg$
T I ON
~~7 ~ Hugh Stephens Ti. U. 1785 °r~hquitz McCallum gay
29. s..cirr •ca o[wr, suruot, trc. 70. aaAt[ Ot INIYNT 11. urrwr a ~a•c 32A. A••[ or rwm•+-rovr. oa•, •rat 328. HOUR
INJURY ~
I
r'~~ORMA- - - -
TIOY 1 a^c.•roN rs»r[r ••r wuwr[• o. axanow c~r+ oR rorwr D4. DE S[AIA*_ MOM IN)URi OCCD AAEO 1[•[rrs t.wrLN !t s°tite Iw awunr
COP.O^cR'S i
U~~ 35A. 1 cttrrr• iw.r D[. 7rrttA •r trrt Mo°r. Dart •rs ?aac[ Sure noN I j5[l. CCRON[R-srGwarrt[ a1A r[.R[ rite[ ' 25C. oast srcwts
f ONLY r»t t•°sn sr•r[a Ac Awauto t. tam 1 Na.a Mtaa a• tlwo.tsr tr•tsnsatwwr 1 -
I` ~e a~:.os~: 0 37. DATE-rn.r., G•r •[•a 3!. wawt •.o A»atss er et.nnr o. t.r.a, o.. 39 rvAaawt• s aut•st a.wr •¦o s•c.•r.a
Burial ust 11L1979 Highland Cemeter Greenfield,Tennessee ~ ~,~336
40. ..wa or rernaa or at ro• ro• rtro• ,c•rw; a su:"• 11. a •a . asr.•r--s / 42. oar[ •ee[.nr n rec •a u..•s..a•
1 P. f P. 13 :t Son . a l m S p r i n ~ s . _1h~a' ,_(r~"~!!-\ . AU610
sYAr~ • S• T IS must be in red t ~ie a .
F.EGISTRAR ~ •
VS-I/ r1.7-••
I
' =...ter. . i~ :o~l:;•• ;ltn ..e arL.:~er.t if th
. r + eilLEl~ 4M• ''EO
ST. LU'''r FLA.
c~:--• ~ _ ion rF• , o P. . ' 'S
i:':';FAG RECD?'
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