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CERTIFICATE OF DEATH 494061
- sTATC oR CALIFOIINIA-O~?ARTMWT OF NEALTM
orr~cs or TFIC sTATE IetwsTwwR o? viTA~ slwnsTlcs h i
la. NAYEOFDECEASEO-t~sTNa~rElfa M•DOEENArE k. WiNAME 2a. DJITCOF DEATFF-~csna ~a*. nu 12a NOVR R
• RONENA ~ F. ~ PLATT March 29, 1977 ~ 9s30 A ~ i
3. SEX COLOR OR RACE S: BIRTHPLACE a~'~",.~,~','O'w'Or 6. DATE OF BIRTH 7. A6E .u.. a.e.saa. v taw w row:a rouAS ~
o Oc 2 1
DECEDENT 8 NAME AND BIRTHPLACE OF FATHER 9. MAIDEN NAME AND 8IRTHPLACE OF MOTHER
PEP.SONAL
DATA
b. CITREN Oi WHAT COUNTRY B. SOCIAL SECURITY NUMBER 12. aaASe[0, rrraa wwco woo*ta 13. NAME OF SURVIVING SPOUSE rr ensE. wrc. sagEp aw+o
onorta aman, .
la. LAST OCCUPATION 1S. ,~,""`a„ ~ ~.~M
~w~~ES,/LOVrIG CowAN+? dt Frw 17. KWD OF OR BU51NES5
Bl.@Ct2`OZO 9t? $1QQtrolyei8
Ida PLACE OF DEAT'H~~i~OR OTHER 61JATIENT FACIRY IUia asmca rs NMNIR oe LOCAflONr idt ed+0[ cm COtlOYT[ urns
PLACE 1•scan .a aA Noti
of Memorial tios ital Medical Center of 12801 Atlantic Avenue 1 Yes
DEATH 180. CITY OR TO11IN 1IBc COUNTY - Ildf. ursn sr atr ~ Osr.ts 0r war. Ilda saasa r esaa. srsw
Lon Beach I Los Angeles I I
T'
usual 19A. USUAL ADORES3 rsnar ar wr~ae oe uoeneasa I9a INStoE ttiV CDwORAtE LrNrs 20. NAME AND ADDRESS OF WFO T
1 esrFVt 1d a O0s
ccsrHl «Econuw 34 Elm Street ~ es L.,:A. Fi~n__ _ ' _
~ 1~- pTM-~ ToMn+ 1~ couNTY 1'~- STATE 17819 Joshua Circle
Great Neck ~ Nassau New York Fountain Valle Ca 9270
ZLL CO::ON~ su
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s~•a 121a PNYSICIAN_ »a~.w.~i.eJ'a ~ia.~u a..aa~
ar 2tt OR w ~s.u a wru '210e~OA7 E
?HYSICIAN'S .~iwsa~ar~c
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w« I~~iOa~ia sesawsn0.a.s~ ~anrasew ~ j J
O R CG RON ER'S *.a ww? er saasso r aua•wa v as ~ aam sa.ra
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CERT;FICATION ~-1; ~ ~ / ~1 ~ ~7~?~ • 4 a~ . 21c A ~ 121s.
FUNERAL cAasaa~ior ~00Mt. oatawwua 122a DATE / , 23. NAME OF CEMETERY OR CR~U1 YO~ Tul1E ari ~0!/r EuErSE NWwEIt
I; D14ANp~ Burial 1 March 31 19 7 New Montifiore Gamete SI
E LOCAL 2S. NAME OF iUNERAL OONECIOR eONrEalONAC7w0ASSU0U 26. r0is~ ~i»owe Q 7. ~ 2d. ~
"C°`a'wers+neou0r
FEGiSTRAR L 8 a 1 n0 - ~7
29. -PART L DEIITN .AS CAUSED 0T: ENTE11 ONLY ONE CAUSE YEN lwE FOR A. _ AND C
I wr uusE . Q
(A) J
OOE AS A OF
u ~ COISOfT10NS. K ANT. MNICN ~ r r / Y~TERfI
CAUSE I/// a ~
< ~ CAVE RSE TO TliE uRIEDF Iel ~ _ ONSET
OF ATE CHOSE IA/. STATINi DUE ~ A OOIISE OF OEATN
t Y DEATH THE UNDERLTIN6 CHOSE
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W 30. PART B: OTNEII SIpwF1CANT CONOIi10N5•- casrawrx a sash wr v sau*u» t.a .aanara assa a..na ~~an r 31 awn a
ns aoa~as
a.MS~i
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0/fYt~arYO. Ma •r Ita1MMN1M.M[M rOOr N•
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d 33. SPEpFY ACCIOEIIT. lOIOaE Or erOerCtOE wJWT •"a~1p`a ru. r.aroar. 35 Mw~ultr r. MOAI( 36rL DATE OF NUIMIM-.a.r. an. tar 1368 HOUR.
J rata.a .r+¦a. snot. 1
a -
0 ~ 37A. PLACE OF YI.RIRY rstAER Alq NYOE~ Or tOC?floN As> tr(r CU 7perrr 37a x""° ns. naca a. ~ asa uos»n taws aosa rn easaa ' .aaa uaaa+rsat rases ~
U 14J URY I sr'r'o0a~~`s w ».c aarxs arsoae +n «r wcr~i'am
a~ri~s°.'~a•
INFORMATION ~ uass
10. DESCFtlE NOM YUURf OCCURRED .auu saasa¦ra s? awsn...o.afaaru. srur +rnn a• ..wt s.ewa sa arraao ~ wor a.
`-TATE _ - A_ B. C_ D. E F.
REGIS"fRAR rl ~ u. ~
i -
• pqi ~ ~ ~ ii' EI
THIS I>t A TRUE CERTIFIED COP'1r 0/ THE J
fiLtO IN THE C(NJNTY OF LOS AHfiELE1 p6PAI1'sM[Ni i
OF HEALTH BERYICEB If R BTiAITS TNIE iiAfr iN f ~ -
_ PURPLE INK
. ~ F E ! 11EC01t01f ERif IEO..,..~ _ .
APR 41977 ~.oo
. 'l 494061
l Llw. A. NIAIrIR oUnllr sf BIISM EMM6M.ENI ~
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