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`��� <br /> �� ������ l�l �� �J � ��� ��� �.J <br />� <br /> 21917—The Auguatine Co., County Suppliea, Grand Island, Nebr. <br /> day �,nd. ;����.� 1��t abov� wr�tten. � <br /> Robt. A.Bar1_ow <br /> ( SEr�,I,) County Jud�e � <br /> r,Qy t�rm ex�ir. es Ja��. 4tlz, 1��5 <br /> Filed for record this 2�th d��.�r o�' Uctober, l���Z,, at 11 :�5 o 'clock A.r��. ��c.�Q� <br /> , <br /> �egis r of eeds <br /> O-C�-O-C)-:)-0-0-0-0-0-�-0-J-(�-0-0-0-0-`?-J-0-G-0-0-0-0-0-G-0-�-0-0-0-0-J�, -�1-��0-�--0- <br /> CERTIFICATE OF DEATH y'�� <br /> M-635 District No. �906 <br /> l. FULL NAME Ic�.a May Martindale Registrar � s No. 665 <br /> �. PLACF OF DEATH: (a) County Los Angeles <br /> (b) City or Town Santa Monica <br /> If ou�side city or tot�Tn limits, write Rural <br /> ( c) NC:me of Hos�ital or Institution Mrs.Brown' s Convalescent Home 42 <br /> If not in hos��3.ta1 or institution, give street number of location <br /> (d) Length of StaST: (Specify whetner years, months or days) <br /> In Hospital or Institut�.on 1 month 3 days <br /> In �his Comr�unity 1 Mo. 3 dys In C�.1,:3_fornia 53 yrs <br />' (e) If Foreign born, ho�Pr l.ong in the U. S. A? years <br /> 3. USUAL RESIDEI�CE OF DECEASED: <br /> �o (a) state California og3c2o � <br /> 19 (b) County Los Angeles <br /> ( c) City or Totan Los An�eles <br /> Ol If outside city or town limits, write Rural <br /> (d) Street No. 1931 Norwood St. <br /> (e) If Veteran, name af War None <br /> � (f) Social Security No. None <br /> �F. Sex Female <br /> 5. Color or Race Cauc. <br /> 6. (a) :�ingle, P�2arried, Widowed or Divorced Widowed <br /> (b) NamP of Husband or Wife Laf�yette M�rtindale <br /> ( c) Age of Husband or Wife if Alive years <br /> 7. Birthdate of Deceased Aug. 9th. 1�59 <br /> Month Day Year <br /> �. Age �l yrs. 3 mos. ?1 d�:,ys If Less than one day old hrs min. <br /> 9. Birthplace (unknown, ) I11. <br /> 10. L1su�1 Occupation Housewi.fe <br /> �. 11. Industry or Business own home <br /> � 12. Name William 'nTiley McCoy <br /> � 13. Birthplace unknown <br /> ll+�. .Maiden n�,me unknown <br /> � I�j. Birthplace unknown <br /> 0 16. (a) Tnforman� Wilbur W.Mar�indale <br /> � (b) Address 206 Santa Monica Blvd Santa Pdonica <br /> 1(. (a) ' Bu.ri al <br /> Lurial or crPm�_tion or removal (b) Date Dec. ; 19�-0 � <br /> ( c) Place Evergreen Cemetery <br /> l�. (a) Embalmer ' s signature Harr� E. Best Jr License P10 15�2 <br /> (b) Funeral Director Utter-��cKinley Mortuaries <br /> Ac�dress ��1�+ Sunset Blvd, Los Angeles <br /> , By Harry E Best Jr. <br /> 19. (a.) Dec 2 1940 (b) J. L.Pomroy M D <br /> � Da'G e Fil ec� Regi s�ered Signature <br /> By M�rgaret H. Walsh <br /> 20. Date of Death: Month Nov. Day 30 Year 19�F0 Hour � Minute 45 P. r�?. <br /> 21 MEDICAL CERTI�'ICATE <br /> � I hereby certify, that I attencied tne deceased from rIov. l, 19�1-0 to Nov. 30, 1;��-0 <br /> � th�.t I last saw her alive on Nov. 2Q, 1�40 and that death occurred on the date and <br /> hour st�,tec� above. <br /> ` Immec?iate ca.use of death Chronic myoc�rditis Duration 2 ye�rs <br /> � Due to <br /> Due �o �;enerali7e a.rterioasclerosis 3 years <br /> Other conditions <br /> (Include pre�nani cy within three months of death) <br /> Major Findings :� <br /> of operz.tions <br /> Date of Operation <br /> oF Autopsy None <br /> PHYSIG2AN Un�.erline the cause to sahich deatn should be charged statistic�lly <br /> � 22. COR�N�R' S CERTIFICATE <br /> I hereby certify, that I he:Ld �n on the <br /> � autopsy, inquest or investigation <br /> rem�ins of the deceased and fir�d from such action that deceased came to h <br /> death on the date and hour stal:ed above. <br /> 23. If death was due to extern�l causes, fill in the foll.owing: <br /> (a) Accident, suicide, or Homiciae? <br /> . (b) Date of Sn�jury � <br /> ( c) ?�here did In,jury occur ? <br /> City or ToT�rn aunty State <br /> (d) Did in,jury occur in or about home, on farm, in industrial place, or in public <br /> - place? ti�'hile at work? <br /> Specify type of pla.ce <br /> ( e) Me�ns of In,jury � <br /> 2�-. 5e�e�e�1a-e� Physician� s Si�nature J.B. Hermadka, M. L�. <br /> (Specify which) <br /> Address Sa.nta Monica Date 12-2-�10 <br /> State of California CERTIFICATE OF DEATH U. �. Dept. of Commerce <br /> DEPARTP��EI�TT QF PUBLIC HEALTH Bureau of the Census <br />