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HomeMy WebLinkAbout0928 - - i _ . / ~ . ~ ~ ~ ~`~SS~ # ~ ; ? . ~ ; ~ ~ C~RTIFI~AT~ OF D~ATH ~ ' ~ } STA7E OF CAUFOftNIA • ~ - - ' _'_'^-'-ST~i[ fl[C /:UYp[R . - . ~ IOC~t RfG151~~710'1 DS•iTtlCt ~VD :t~~l?lCATE MJYi[R_ IF.. NAME OF DECEDENT--FIRr 9T T 10. NIO~LE ~ IC, LAST 2A. D11T! Of OUTIt ~~¢Mtr, s.r, rn~~ ~28. wcu~ ~ GEORG~ ~ - M. : _ POOR _ A~CEMBER 20, 19$1 i 0717 ~ SEx i. RACE 5. E~I?NICITY i. DATE OF BIRT}I 7. AGE' ~r r¦~u ~ ~u~ ~r p~:~~ t~ woa~s Y9tiMl. 6~f1 MOY~S r~\7t({ MALE WHITE ~JUN~ 10, 1909 _ 72 l ~ , - 'P~RSO AL DECED~Ntr ~;~!~~'~~USETTS t+*f 'HAROLD,~P~~OR i-TxMASSACHUSETTS . ~1MARY NMILLERr-~tM.~SSACHUSETT5 ' ~ DATA F . 11. crtitat a waa~ cc~rtu 12. suu~ su~~ir~ Mc~u~ 1~. Muuu sr.ro~ ^ f1. NJ1M[ Ot fURY1~t116 3MVf~ :t~ vu[. trtu ~ ~ U.S.A. 012-09-1770 MA~.:IED ~~~hCE DALE IS. hirur oec~ a~io li. :~~r.~te or tta~~ 17. CMft01[t 11? 7RI.IM/tOftQ~ so u~Tp 10. K~M~ o? hcusrar o~ nu~ns ASS~. ~r~ne T~isoccy3trow ~}~XOri Go~rp~ration Oil Itefinexy ~F V , f9A. Yc~n ~rs~s cc-~nat ~ou~tu ~innt 1110 hORCU Ot lOLlt10N! 1lp. 19C. C~tr ~a Tps• ~ usun~ Holiday Ouk 10725 S.~~ AIA ~ Jensen Beach RESIDENCE 19D, couw~~ - = 9E. Si~tt YO. MA!t[ AND AOD~[SS 0I IifO~M1MT-~tU~-tatw~? ~ Martin Cc~. ~ Florida . George Poor, Jr. Son ~ 21A. ?l~C[OFO[~TX - ~218. COUNiY 2742 Heatherstone Dr. . P OF E ~rin General Hospital ~ Marin San Rafael CA 94903 t - ()~A~"!j ~ 21C• STR[[i Ao~R[SS tst~t[t i~o ruM~~e oe ~o:aro~~ ( 21D. [lif OR TOYN , 2S0 Bon Air Road ~ ~ San Rafa~l ~ - 22. DEATH WAS CAUSEO BY: IENTER ON~Y ONE CAUSE PER LINE FOR A, 0, ANO•C) 21. r4s s4ir ~~ro~t~• IMMCOIATE CAUSE ~ ~ o cc~o~tet . ~ . - . Probabl~ cardiac arrythmi a ~ ~~••o•~. Xes - ~ CONDIiIOFf, II 111t. -'r~~- - ~4T~ C OF E O?[ TO.O! Af n tONfLGU[tC[ Of INi[lYIL =s. M.s ~~ont t~uc~rroe r~itw a~r[ ~~tc io DEATH ..~,.v~z,.,«.~,~. ~s, . Cardiovascular d~.sease ( liistory) sOAS[TN No ~ ' fT~i1RG iMt OYpI~. . OY[ i0. Ot 4i ~ COiSLOVCM<[ N AMD Z~. M1f A~iO/fT tt~fOf~tL\7 ' Lr~MS Ca4fi 1~i1. - . , . . 0[~TM ~ No Z~. OIMI~ COM9RIJNi CO'lill~UT~~6 ~ItT NoT Rllll[O 701ML IMM[Ol~i[ t~uS[ O~ DLxiA 7. Mr~S Oi[t~111fe /L:fOtY[~ !4! lfl~ CrieitlOM IM II[MS 2t O~ !1• Congestive f~ilure; chronic atrial fibri. ~~a~9:.c~n; - o~*~ - 2 A1 • ~f ta7 .~i-~~aYu c r occece oe iinc' . 28C. o?te s~za~a 2~D. ~r~s~uati•s utt~st ~ar~te ~ PNYSI• +~ra ta~tt S~+tio F?ow Twt cadttt Srxtto. I CUN'S t ~~r~~n~o occcoi+.r zivcc ~ ~~.ct sxr nccaaur ~ucr( ~ _ ~ CERTIFICM ~o. c+. i ([vT[t MO. Ca. 1~.) ' jgE, TT?E ?iiYSIC1~N•S MAMC ARD ADD2E55 ~ 710N ~ ~ ~ ~ ~ , ~ _ 29. srtc~?i ~tc~et~t. iu~t~ot. tit. 30. ?UCf OF IhJURT ~ • 71. IAlutr ar yci[ 32A. o+rt or ~wio~i-~o~~r. rr•• 1~2~5 M+OUx • ~ i~~uRY . NATURA~ - ~ ~ 1NFORMA• ' ' - , '(~ON 7~• louTlo~ ~st~tct awo ~~¦~ta o~ toc~~~o~ ~ao c~ir c~ ~vi~? ~ 74. ocsiail[ NoN IMJU~Y O[CURiFO (~~[wis rK~ce ccso~r[o iri~~r~ ~ CORONER'S • ' ONLY 3~A. i t[mn Trar os4rM o:a~~to ?r nc eieae, o~ie ia~ ?Lii[ STai[D ?tOfl ~ 3SB. ~ROH[~~~' tYRt ;o cs 4;suy~ ~ 35C. eatt s~~~ar t~~ uvics sr~uo. as Rcoun~o ~r uv t Mav[ Hue a~ ~tconcsr-~aresnsanoa~ I j+ • 1~.'fl? 1~ ~6. oisrosino• 37. DATE-MO~iM. 0~1. ~l~• jd. 71tMt A11p ApDltfi Cf C[f~(Tt~f O~ Ct[~T . ~~•s a~cc~s~ rc~~c~ ~r~ s~c+aTC c Cremation DEC 23, 1981 Pleasant Hill Cemetery, Sebas Oj~01, Calif. Not mbalmed ~0. aara ur r~rc•at nrtcroe ~oi ~c~so+ ?c~inc ~s sucn~ AI_ 10C41 ~[GlfT~li~~ •T9t[ • _ . wr[ .:crrri~ ~r ! a ~ RUSSELL ~ GOOCH FUNERAL CHAI'EL F-63 1-~A ~ ~ r~ t QEC 2'~ . c/=7C... Gc_~ r,--•.--c~--s'-:- ~ STATE A. B. C. . D. E. F. ^ • REGISTRAR ~ • ~ ' - vs•i1 uo-~e~ - ~ 5'78~54 - . . CERTIFlCATI ,,StATEM~AlT ~ i ~ - ~ t;'y.- f M . ~~*a ~s fhot ~'~d#tached ~S a trua and corrcftt ; ,1~$~ -3 fii'~ ~ 2~ copy of the vital record..~ is on file in ti~is a~'tca and of~ ' ~ - ~~t fC ~Kf sr ~r~~ ; M/~~'1 ~ iJlTt ~ lega~ •j t _ - . ' - ~ . i. Si.ll;~1E E(.~~ THF!bo 1? Ht.~ ' D; ' (?{)L~R4'Uc,f' = • 's. _ ~~'+OUNTY:HEALTH OFFICER E ~ zIER?S r:~C~l . ( . . ~I? 's .~'r" ~ : t ~ . ~ De ut : Re istrar ~'s ~z SICNATU E OF CE fNG pFFIG1At' 1 I ~ , OfF~SiAI Y1TLE - _ I " ; ~ • ~ COUNTY O~ ~~?4R;N ' - " r :i`-' DEPT. HEALThi~Jlti~~ Huh~~( SiE~vi~ ,=-~C-2 3~°8l - ~ . ?LACE OF CERTIFICATIQ/[. ` a -ti ~ , ~ , ~ f < ~yF DATE OF CERTIFICATIOM ' . ROOM 280, CIVtC C~t~'~t's#2~ ,~rJ1El.. CALIF. 4A913 j'` I _ 1:- f~ ~ - f' ~ - - - F S{_~ f.f _i~- _ { ~ - ` :i?±' j ~ - ~ • - - . _ I . - _ - ~ ~ - - ~ Boi~( e~IC7J FAbf