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Aadit 8Edtb°th8tCityBai°GrlAd na1 Wh8pi! S <br /> NEGISTRATION 3f+01 CERTIFIED COPY OF DEATH RECORD RE'GISTRAR•S <br /> DISTRICT NO NUMBER <br /> NAME OF DECEASED—FIRST NAME i MIDDLE NAME - 1 LAST NAME <br /> Viola l I Chaffee . <br /> DATE OF DEATH—MONTH.DAY.YEAR SEX COLOR OR RACE DATE OF BIRTH <br /> July 22, 1955 Female White September 19, 1920 <br /> MARRIED.NEVER MARRIED.WIDOWED NAME OF SPOUSE—(IF MARRIED) <br /> DIVORCfQ tried Clyde Chaffee <br /> NAME OF FATHER MAIDEN NAME OF MOTHER \-- 11 A b h <br /> George Alton Iottie McNdble <br /> PLACE OF DEATH—CITY OR TOWN - PLACE OF DEATH—COUNTY <br /> Sacramento -rySy-l733� ��_°T`1 Sacramento <br /> DATE RECEIVED BY LOCAL REGISTRA,Rty- _+ Y'•4 DATE(SI OF CORRECTION 15).IF ANY <br /> July 26, 1955 I a, iii <br /> This is to certify, that oin a uA pnd correct copy of statements appearing on she <br /> record�af h_qf.theme•o4e.nced decedent, as filed in this office <br /> s.: <br /> SIGNATURE OF CERTIFYINGVF OFFICIAL TITLE <br /> ."'1,% ,, BB Registrar <br /> PLACE OF CERTIFICATION ` - DATE CERTIFIED <br /> Sacramento CI flBa" 'Dept. AUG 11 i55 <br /> STATE OF CALIFORNIA REV.7-149 DEPARTMENT OF PUBLIC HEALTH <br /> FORM R&S-110 <br /> DEATH CERTIFICATE 3 z: <br /> State of California City Health Department <br /> to <br /> Viola Chaffee <br /> State of Nebraska <br /> Ccunty of Hall j ss <br /> Entered on Numerical index and filed <br /> for record in Office of Register of <br /> Novvembenr the r �r day of <br /> 19 at <br /> o'clock and 11:5- <br /> tninute '_�Vl. <br /> and recorded in Book __________. of <br /> _�Qiscsl a Page - <br /> GLw�/ <br /> • Register of Deeds <br /> Deputy <br /> Fees <br /> -- 42. / 3 <br />
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